Systematic Identification of Cardiotoxic E-Cigarette Flavorants

The goal of this study is to examine how individual flavorants in e-cigarettes modify the effects of e-cigarette aerosol exposures on the electrical activities of the heart (i.e., cardiac electrophysiology), leading to heart arrhythmias and functional remodeling. Researchers will identify short-term and long-term effects of flavorant exposure on cardiac electrophysiology in mice by using various state-of-the-art analytical approaches. Study aims are: (1) to identify the short-term effects of flavored e-cigarette aerosol inhalation on cardiac electrophysiology; (2) to examine the direct impact of flavorants on cardiac electrophysiology by examining cardiac myocyte function; and (3) to clarify the impacts of individual flavorants on the short- and long-term impacts of e-cigarette aerosol exposures on cardiac electrophysiology, structure, and function. This study will provide new data on the cardiac toxicity of e-cigarette flavorants.

Evaluating the Potential Impact of a Menthol Ban in Cigarettes and E-Cigarettes Among Current Menthol Smokers

The goal of this study is to model the impact of different menthol regulatory scenarios on real-world smoking behavior. Study aims are: (1) to examine the impact of banning menthol flavor in cigarettes and e-cigarettes on smoking behavior and (2) to investigate whether outcomes differ by race to understand the impact of menthol ban policies on Black (vs. non-Black) individuals, given high rates of menthol cigarette use in this population. Researchers will recruit 150 adults (ages 21+) who currently smoke menthol cigarettes and will provide them with cigarette and e-cigarette products to use for 8 weeks; subjects will be randomized to one of three study conditions in which they will receive products as follows: (1) no menthol ban (menthol cigarettes and menthol flavored e-cigarettes), (2) menthol ban on cigarettes only (non-menthol cigarettes and menthol flavored e-cigarettes), or (3) menthol ban on both cigarettes and e-cigarettes (non-menthol cigarettes and tobacco flavored e-cigarettes). A follow-up survey at 12 weeks will assess changes in the number of cigarettes smoked per day (the primary study outcome) as well as percent days smoke-free, changes in nicotine dependence, and motivation, confidence, and intention to quit smoking. Findings may inform regulatory activities related to menthol.

Novel “Tobacco-Free” Oral Nicotine Pouches: The Impact of Product Features and Marketing Influences on Abuse Liability, Perceptions, and Use Behavior in Smokers and Non-Nicotine Users

A novel class of oral nicotine pouches that contain a nicotine powder instead of tobacco leaves has recently emerged; these pouches often contain non-tobacco flavors (e.g., fruit) with known appeal to youth. The goal of this study is to describe nicotine pouch product features and marketing tactics that may drive initiation and continued use among smokers and non-nicotine users, including youth. Study aims are: (1) to examine how pouch flavors and nicotine doses impact pharmacokinetics (PK), or how nicotine moves through the body, and pharmacodynamics (PD), or the effects a person feels after using a drug, in cigarette smokers; (2) to characterize nicotine pouch marketing tactics in advertisements and examine the influence of these tactics on cigarette smokers’ and youth non-nicotine users’ product perceptions; and (3) to examine how a common marketing tactic (e.g., “tobacco-free” descriptors) impacts use behaviors and PK/PD effects in cigarette smokers and non-nicotine users. To achieve Aim 1, 28 smokers (ages 21+) will use pouches of different flavors (tobacco, mint, fruit) and nicotine doses (low, high), and their own brand of cigarettes over seven laboratory sessions, and PK and PD effects (e.g., subjective abuse liability, tobacco withdrawal) will be assessed. In Aim 2, researchers will review nicotine pouch advertisements over 5 years to identify/monitor marketing tactics and examine, via web-based experiments, how common tactics influence product perceptions (i.e., perceived harm, addictiveness, appeal) and use intentions among 2,500 adult (ages 21+) cigarette smokers and 2,500 youth (ages 13-20) non-nicotine users. In Aim 3, researchers will conduct a second laboratory study with 60 smokers and 60 non-nicotine users (ages 21+) to determine how a common marketing tactic identified from the Aim 2 marketing analysis (“tobacco-free” descriptors) impacts pouch use behaviors and PK/PD effects. Findings may inform future regulatory activities related to novel oral nicotine pouches.

The Effect of Menthol on ENDS Users’ Dependence, Respiratory, and Toxicants Emission Outcomes

The goal of this study is to clarify how menthol affects electronic nicotine delivery system (ENDS) users’ experience and puffing patterns, which in turn affect dependence, exposure to toxicants, and clinical outcomes. In this study, 200 current/past month closed-system ENDS users (ages 21-35) will attend two laboratory sessions and use their ENDS once with menthol flavor and once with tobacco flavor. Study aims are: (1) to test the effects of menthol vs. tobacco flavor on subjective, puffing, and respiratory outcomes including pre-post-use assessment of craving, withdrawal, satisfaction, harm perception, intention to quit or use, respiratory functions, and symptoms (e.g., dry mouth, irritation, cough, palpitation, nausea); and (2) to use a smoking robot to measure the effects of menthol vs. tobacco flavor on ENDS emissions of 14 aldehydes. Findings may inform future regulatory activities related to the use of menthol flavor in ENDS.

The Impact of Menthol Flavoring on Switching in Adult Menthol Smokers

More information about the impact of menthol-flavored e-cigarettes in enabling menthol cigarette smokers to switch to e-cigarettes would be useful. The goal of this study is to compare the efficacy of menthol-flavored versus tobacco-flavored e-cigarettes in facilitating switching from combustible cigarettes to e-cigarettes among adult menthol smokers. Researchers will randomize 800 menthol smokers (≥ age 21) into a 12-week trial comparing menthol-flavored and tobacco-flavored e-cigarettes, with follow-up at week 26. Study aims are: (1) to compare the effectiveness of menthol versus tobacco e-cigarettes at facilitating switching (measured by cigarette and e-cigarette use patterns) at week 12; (2) to compare tobacco harm reduction of menthol versus tobacco e-cigarettes (measured by self-reported health-related quality of life, expired carbon monoxide, respiratory measures, and blood pressure) at week 12; (3) to compare the acceptability of menthol versus tobacco e-cigarettes (measured by product use; effects on withdrawal, craving, and dependence; and subjective and sensory effects) at week 12; and (4) to examine the long-term use of menthol versus tobacco e-cigarettes at week 26. Findings may inform future regulatory activities related to menthol flavoring in e-cigarettes.

Nicotine Flux, A Potentially Powerful Tool for Regulating Nicotine Delivery from Electronic Cigarettes: Significance of Nicotine Flux to the Rate of Nicotine Delivery and Subjective Effects

The rate at which electronic nicotine delivery systems (ENDS) emit nicotine (“nicotine flux”) can be predicted based on knowledge of a few device design and operating variables. The goal of this study is to provide empirical evidence demonstrating the relationship between nicotine flux and nicotine delivery and between nicotine flux and the physiological and subjective effects that support nicotine dependence. Study aims are: (1) to examine the relationship between nicotine flux, nicotine form, and the rate and dose of nicotine delivery, and (2) to assess the relationship between nicotine flux, nicotine form, and subjective effects. To achieve Aim 1, participants will puff on ENDS devices under conditions that differ by flux and form while arterial blood is sampled for nicotine levels; the outcome will indicate the degree to which nicotine flux and form determine the speed and dose of ENDS nicotine delivery, and thus, abuse liability. To achieve Aim 2, participants will use ENDS devices with varying nicotine fluxes and forms, and dependency measures such as urge to smoke, craving, and abstinence will be assessed; the outcome will indicate the degree to which nicotine flux/form influence subjective effects related to dependency, puffing intensity, and toxicant exposure. Findings may provide evidence for using nicotine flux to inform possible regulatory activities.

CTP Supplement to Parent Grant: Chronic Hookah (Waterpipe) Smoking, Vascular Dysfunction, Inflammation and Oxidative Stress

As a supplement to a parent grant, this study will further examine the long-term health effects of hookah smoking by evaluating autonomic nervous system regulations of the heart and identifying additional biomarkers of harm that could be used to evaluate and monitor the effects of chronic hookah smoking on cardiovascular health. In a group of generally 34 healthy chronic hookah smokers ages 21-49 who do not smoke cigarettes — matched with 34 cigarette smokers and 34 nonsmokers — researchers will examine: (1) cardiac sympathetic nerve activity measured by heart rate variability; and (2) biological markers of inflammation and oxidative stress, including: (a) interleukin-6 and tumor necrosis factor-a; (b) free polyunsaturated fatty acids and oxidized metabolites, assessed by mass spectrometry; and (c) concentrations of glutathione, bilirubin, heme oxygenase-1, and functional activity of paraoxonase1, determined by colorimetric and enzymatic assays. Findings will provide new information about the cardiovascular effects of hookah smoking.

Determinants and Health Effects of Dynamic Changes in E-Cigarette use Before, During, and After Pregnancy

The goal of this secondary data analysis is to examine changes in maternal e-cigarette use before, during, and after pregnancy, determinants of these changes, and their effects on maternal and infant health. Study aims are: (1) to examine determinants of changes in e-cigarette use before, during, and after pregnancy; and (2) to assess health outcomes associated with changes in e-cigarette use (discontinuing, switching, and relapsing) before, during, and after pregnancy. Researchers will analyze data from two large U.S. national studies: the Pregnancy Risk Assessment Monitoring System (PRAMS) with N=153,336 existing mothers during 2016-2019 plus new mothers in 2020-2021, and the Population Assessment of Tobacco and Health (PATH) Study with N=4,392 existing pregnancies in waves 1-4 during 2013-2017 plus new pregnancies in wave 5 during 2018-2019 and the adult telephone survey in 2020. Potential determinants of e-cigarette use changes to be evaluated will include socio-demographics, pregnancy intention and characteristics, baseline e-cigarette use and product features, risk perception of e-cigarette use, concurrent substance use, and time of survey. Prenatal outcomes will include gestational weight gain and gestational duration. Neonatal outcomes will include small-for-gestational-age birth, mode of delivery, and length of infant hospital stay. Postpartum outcomes will include breastfeeding and postpartum depression. Findings will provide new information about changes in e-cigarette use and its effects on maternal and child health.

Can Machine Generated Nicotine Yield Predict Human Nicotine Exposure from ENDS?

The goal of this study is to examine whether machine-generated nicotine yield from electronic nicotine delivery systems (ENDS) can predict human exposure to nicotine. Study aims are: (1) to determine whether nicotine yields generated from machine-vaped ENDS are associated with human nicotine exposure following prescribed or ad libitum ENDS use, and (2) to determine which machine-vaping regimes (e.g., CORESTA, intense, playback of human puff topography), if any, are most effective for estimating human exposure to nicotine. Researchers will also investigate how changes in ENDS nicotine yield may affect nicotine pharmacokinetics, pharmacodynamics, non-nicotine HPHC exposure, subjective effects, and puff topography. In this randomized study, 32 current ENDS users (ages 21-65) will complete four experimental visits during which they will use an ENDS containing one of four e-liquid nicotine concentrations (i.e., very low, low, medium, high) under prescribed and ad libitum use conditions; researchers will then measure nicotine pharmacokinetic parameters (e.g., maximum plasma nicotine concentration) to determine nicotine exposure and compare it to machine-generated yields. Results will help determine whether nicotine yield data can be used to estimate human exposure to nicotine from ENDS, whether these data can be used to draw inferences regarding ENDS abuse liability, and whether certain machine-puffing regimens are most suitable for estimating human nicotine exposure from ENDS.

Strengthening Cigar Warnings to Prevent Adolescent Use

In 2016, the Food and Drug Administration (FDA) mandated six rotating text-only warning statements to be placed on little cigar and cigarillo (LCC) packaging. The goal of this study is to advance the science on LCC warnings that are effective for youth ages 15-20 who currently use, have ever used, or are susceptible to using LCCs, especially Black/African American youth. Study aims are: (1) to identify the most effective images to pair with FDA-mandated LCC text-only warning statements using a youth advisory board and a quantitative online survey delivered to 500 youth; (2) to examine whether LCC warning size (30% vs 50% on the LCC package principle display panels) and type (text-only vs. text+image) affect perceived message effectiveness of LCC warnings among an online sample of 500 youth; and (3) to conduct a randomized controlled trial with 900 youth to test whether the most effective LCC warnings from Aim 2 reduce willingness to use LCCs (compared to the text-only 30% size FDA-mandated LCC warnings and a control condition). Findings may inform regulatory activities related to LCC warnings.

Effect of Tobacco Use Patterns on Toxicant Exposure and Successful Cessation: A Longitudinal Study among US Adult Cigarette Smokers

Researchers will analyze data from Waves 1-5 of the Population Assessment of Tobacco and Health (PATH) Study to identify groups of adult smokers defined by their toxicant exposure and investigate how levels of nicotine dependence and patterns of tobacco use could impact adults’ ability to achieve successful smoking cessation (smoking abstinence ≥3 months). Study aims are: (1) to analyze data on biomarkers of exposure to tobacco chemicals (i.e., nicotine, tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons, volatile organic compounds) in 8,000 adult current cigarette smokers and group those smokers based on toxicant concentrations detected in urine; researchers will examine whether groups differ by personal characteristics, smoking behaviors (e.g., menthol vs. non-menthol smoking; cigarette smoking only or polytobacco use), and level of nicotine dependence; and (2) to describe trends in nicotine dependence and smoking behaviors to identify characteristics and behaviors of adults who achieved successful smoking cessation. Findings may inform regulatory and research activities that address tobacco-related toxicant exposure and will shed light on barriers and facilitators to achieving successful smoking cessation in adults.

Development of Biomarkers of Exposure and Effects for Electronic Cigarette vs. Combustible Cigarette Use

E-cigarette use has been associated with a variety of diseases, including cancer. The goal of this study is to detect genetic and epigenetic (i.e., behavioral, environmental) alterations in key genes in the oral and blood cells of 45 healthy adult vapers and 45 healthy adult smokers in comparison to a control group (45 nonsmokers/non-vapers) matched for age, sex, and race. Study aims are: (1) to screen for the deregulation (i.e., functional impairment) of disease-related genes in oral and blood cells of vapers and smokers as compared to controls; (2) after identifying the deregulated genes, to employ targeted next-generation sequencing (a method of analyzing DNA) to detect genetic changes in the deregulated genes; and (3) to employ targeted next-generation sequencing to detect epigenetic modifications to the deregulated genes. As a secondary goal, researchers will identify correlations between the identified genetic changes and subjects’ tobacco product use patterns and product characteristics (e.g., e-cigarette device features; e-liquid content; cigarette brand, type, and chemical constituents); this will clarify the impact of vaping/smoking dose and product characteristics on the biological effects of e-cigarette use vs. cigarette smoking. Study findings will identify gene changes that can serve as biomarkers to differentiate among vapers, smokers, and nonsmokers/non-vapers, thereby indicating the health risks and/or potential benefits of e-cigarette use relative to smoking.

Pulmonary Toxicological Evaluation and Chemical Interactions of Menthol, Mint, and Tobacco Flavored E-Cigarette Products

Menthol/mint and tobacco flavors contain harmful chemicals that can cause adverse cellular and molecular changes in lung tissue. The goal of this study is to identify constituents of menthol/cooling and tobacco flavors and their pulmonary toxicity and to determine potential biomarkers of disease. Study aims are: (1) to identify the chemistry of menthol, menthol-like (cooling), and tobacco flavors, including flavoring chemicals and secondary products formed upon aerosolization; (2) to determine the in vitro and in vivo toxicity and health effects of menthol, menthol-like, and tobacco-flavored electronic nicotine delivery systems (ENDS) in EpiAirway 3D tissues (tissues constructed of human tracheal/bronchial epithelial cells) and in mice under normal and pre-existing respiratory conditions (chronic obstructive pulmonary disease and asthma) (3) to determine in vitro and in vivo toxicity and health effects of exposure to responsible flavoring chemicals identified in Aim1 using EpiAirway 3D tissues and mice under normal and pre-existing respiratory conditions. Findings will provide new information about lung toxicity caused by menthol and tobacco flavored e-cigs, identify disease processes of asthma and COPD upon switching to menthol and tobacco flavors from combustible cigarettes, and identify the culprits in these flavored e-cigs causing lung disease and exacerbations, thus, providing critical information for regulation of constituents of these ENDS.

Impact Analysis of Flavor Restrictions and Tobacco 21 Policies on Youth Tobacco Use

Sixteen states and the District of Columbia enacted state-wide tobacco 21 (T21) policies prior to passage of the federal T21 law in December 2019, and seven states have recently enacted bans on flavored tobacco products. The goal of this study is to examine the impact of state flavor restrictions and state and federal T21 policies on disparities in tobacco use among youth and young adults aged 14-24 years. Researchers will analyze data from two surveys: the Behavior Risk Factor Surveillance System (BRFSS), an annual national phone-based survey of health-related behaviors among adults aged 18+; and the Youth Risk Behavior Survey (YRBS), a biennial school-based survey of health-related behaviors in 44 states. Study aims are: (1) to evaluate the impact of flavor restrictions and T21 policies on tobacco use (cigarettes, ENDS, smokeless tobacco) across age (18-20 vs. 21-24) and examine the impact of both policies on tobacco use across socio-demographic strata, using BRFSS data; (2) to evaluate the impact of flavor restrictions and T21 policies on tobacco use (cigarettes, ENDS, smokeless tobacco, cigars) across age (14-17 vs. 18) and examine the impact of both policies on tobacco use across socio-demographic strata, using YRBS data; and (3) to examine the impact of Covid-19 state closures and re-openings on tobacco use overall, by age, and across sociodemographic strata, using data from both surveys. Findings may inform future regulatory activities related to youth and young adult tobacco use.

Countering E-cigarette Marketing in the Retail Environment among Adolescents and Young Adults

Many adolescents and young adults directly purchase e-cigarettes from brick-and mortar retail stores. The goal of this study is to identify appealing and influential characteristics of e-cigarette marketing in the retail environment that impact adolescent (ages 11-18) and young adult (ages 19-21) e-cigarette purchase and use. Study aims are: (1) to examine adolescent and young adult descriptions of e-cigarette marketing in the retail environment and its influence on their e-cigarette purchase and use behavior; (2) to identify the most appealing characteristics of e-cigarette retail marketing that influence purchase and use; and (3) to develop and evaluate the effectiveness of an e-cigarette counter-marketing lesson to reduce adolescents’ intent to use and actual use of e-cigarettes. To achieve Aim 1, researchers will conduct focus group discussions with adolescents and young adults who have either never used e-cigarettes or have ever used or currently use e-cigarettes; the study will include a separate focus group for youth peer advocates working on e-cigarette prevention (total participants = 72). To achieve Aim 2, researchers will survey 2,250 adolescents and young adults to identify how and which e-cigarette marketing characteristics influence e-cigarette purchase and use; the survey will include a discrete choice experiment. Aim 3 will involve a randomized controlled trial that will assign 950 adolescents to one of two conditions: (1) a newly-developed online counter-marketing lesson about e-cigarette marketing in the retail environment, or (2) an existing online e-cigarette overview lesson to assess influence on intent to use and actual use of e-cigarettes. Findings may inform future educational and regulatory activities related to e-cigarette retail marketing.

Personal Factors, Product Characteristics, and Changes in Biomarkers of Exposure among Cigarette Smokers Who Switch to Noncombustible Tobacco Products

The goal of this study is to evaluate the factors associated with transitioning from cigarettes to noncombustible tobacco products (e.g., smokeless tobacco, e-cigarettes) and assess the potential of noncombustibles as a harm reduction strategy. Researchers will evaluate four possible trajectories — continued smoking (least optimal outcome), complete cessation (most optimal outcome), exclusive noncombustible use (possible harm reduction) or dual/poly tobacco use (unlikely harm reduction) — through an analysis of Population Assessment of Tobacco and Health Study data. Study aims are: (1) to identify personal characteristics (e.g., sociodemographic characteristics, smoking history, harm perceptions, exposure to messaging) associated with switching from cigarettes to noncombustibles; (2) to describe product characteristics (e.g., cigarette characteristics, noncombustible characteristics such as flavor and nicotine content) associated with switching; and (3) to examine health outcomes and exposure biomarkers in smokers who have switched. Findings will provide new information related to switching from cigarettes to noncombustible tobacco products.

Modeling the Impact of Tobacco Regulations on US Future Trends of Chronic Obstructive Pulmonary Disease

The objective of this research project is to build a chronic obstructive pulmonary disease (COPD) model based on individual cigarette smoking histories that will be used to predict the long-term population impact of two FDA tobacco regulatory scenarios on COPD disease burden. Study aims are: (1) to analyze data from a database of US adults with COPD (the COPDGene Study) to determine the impact of smoking behavior changes on lung function decline and COPD mortality; (2) to develop a COPD simulation that estimates future COPD incidence, prevalence and COPD-associated respiratory and lung cancer deaths based on individual smoking histories; and (3) to predict possible future trends in COPD morbidity and mortality under two FDA tobacco regulatory scenarios: cigarette pack and advertisement graphic health warnings (implementation of a Final Rule) and a menthol cigarette ban (planned). Findings will provide new information about the impact of tobacco control policies on COPD trends.

CTP Supplement to Parent Grant: Impact of Flavor on Youth & Young Adults Use Intention, Abuse Liability and Perceptions of Cigarillos

The goal of this project supplement to the parent grant is to determine how the removal of flavors from cigarillos could impact co-use of cigarillos and cannabis, and whether that impact is related to perceptions of appeal or harm. Specific aims are: (1) to analyze parent study data on 361 young adult (ages 21-28) cigarillo users to determine the relationship between use of flavored cigarillos and co-use with cannabis (including blunts), and (2) to conduct one-on-one interviews with a subset of 38 participants to expand findings from the parent study, including understanding flavor appeal, perceived harm, and product substitution, and to assess these factors in the context of co-use with cannabis. Findings will provide new information about the influence of flavor on young adult co-use of cannabis and cigarillos.

Evaluation and Comparison of Impacts of Flavored Waterpipe Tobacco and Electronic Waterpipe E-Liquid Formulation Variations on Toxicant Yields and Particle Size Distribution in Mainstream Emissions

The popularity of flavored waterpipe (WP) smoking has expanded in recent years to flavored tobacco-free alternatives, including electronic WP (EWP). EWP replaces the traditional WP bowl and heat source with an electronic head filled with flavored, nicotine-containing liquid (e-liquid), turning the WP into an electronic nicotine delivery system (ENDS). The goal of this study is to compare the impact of variations in flavor profiles, humectants, sugar levels, and heating temperature in a variety of commercially available WP tobaccos and EWP e-liquids on hazardous and potentially hazardous constituents (HPHCs) and other toxicant yields as well as particle size distribution in mainstream WP emissions. Specific aims are: (1) to characterize variations in formulations of a variety of commercially available WP tobaccos and EWP e-liquids by determining the flavor profiles and humectant and sugar content; (2) to determine HPHC and other toxicant yields and particle size distribution in mainstream emissions generated by machine-smoking the WPTs using a research-grade electric heater operating at a high and low temperature; and (3) to determine HPHC and other toxicant yields and particle size distribution in mainstream emissions generated by machine smoking the e-liquids at a high and low EWP power setting. To achieve Aim 1, nine WP tobaccos and nine e-liquid flavors within popular flavor categories will be selected and chemically analyzed using established methods. To achieve Aim 2, WP tobaccos selected in Aim 1 will be machine-smoked using a human-derived smoking regimen; mainstream emissions will be analyzed for volatile and semivolatile HPHCs, particle size distribution, and other toxicants. The heater and tobacco temperature will be monitored and recorded. To achieve Aim 3, EWP e-liquids selected in Aim 1 will be machine-smoked as in Aim 2 but using an EWP head with variable power. Findings may inform future regulatory actions related to WP and EWP.

Survey of Risk Factors of Lithium Ion Batteries Used in ENDS

Electronic nicotine delivery system (ENDS) lithium-ion battery-related overheat, fire, and explosion (O/F/E) incidents have increased in recent years, but limited information is available about ENDS-related O/F/E risk factors. Efforts to understand causes of ENDS-related O/F/E incidents suggest that specific products and certain user practices may increase the risk of ENDS-related O/F/E incidents. The goals of this project are to collect data from a representative sample of 6,000 U.S. adult ENDS users via an online survey to identify user practices, ENDS devices, and batteries that may increase the risk of ENDS-related O/F/E incidents, and to estimate the prevalence of O/F/E incidents. Findings may inform future regulatory activities related to ENDS.

Multi-Parameter Investigation of Factors Controlling Carbonyl Emissions from Electronic Cigarettes

Carbonyl compounds, such as formaldehyde, a known human carcinogen, are among the hazardous and potentially hazardous constituents (HPHCs) found in e-cigarette aerosols. Researchers have reported numerous factors that influence e-cigarette carbonyl production (e.g., e-cigarette type, power, coil material, e-cigarette liquid (e-liquid) composition, topography), but differences in sampling methodology and testing protocols and a limited number of parameters investigated in individual studies have contributed to controversy regarding carbonyl levels in e-cigarette aerosols and the role individual factors play in their production. The goal of this study is to resolve some of the outstanding questions regarding e-cigarette carbonyl emissions by performing comprehensive testing of popular devices that are representative of three e-cigarette types (a cig-a-like, a sub-Ohm “mod”, and a “pod” type) under a variety of use patterns. Study aims are: (1) to test different carbonyl collection methods using a NIST-traceable formaldehyde standard and e-cigarette aerosols containing different amounts of liquid particulates, and select the best method for subsequent tests; (2) to investigate interactions between the main flavoring compound classes with e-cigarettes that have fresh and aged coils at different temperatures and e-liquid formulations; and (3) to investigate how different combinations of power, puff topography, and e-liquid viscosity affect carbonyl emissions of the e-cigarette types. Findings will help determine the optimal sampling methodology for carbonyls in e-cigarette aerosols and may inform future regulatory activities related to e-cigarettes.

Receipt and Use of Prohibited Free Samples of Tobacco Products Among Adult Cigarette, Cigar, and/or Smokeless Tobacco Users, 2020

On March 19, 2010, FDA finalized regulations restricting the distribution of free samples of cigarettes, roll-your-own cigarette products, and smokeless tobacco in the U.S. (excepting free samples of smokeless tobacco distributed in “qualified adult-only facilities”). This ban was extended to cover all tobacco products, including e-cigarettes and cigars, when the Deeming Rule went into effect on August 8, 2016. More information about tobacco product free samples distribution since the regulations went into effect would be useful. Using data from the National Panel of Tobacco Consumer Studies (TCS Panel), which includes approximately 4,000 U.S. adult current cigarette, cigar, and/or smokeless tobacco users, this study will report on free samples receipt and use behavior for cigarettes, cigars, smokeless, and e-cigarette products; locations where free samples are received; top brands received; and demographic and behavioral characteristics of recipients. If sample sizes are large enough, the following may also be examined: how and/or where tobacco users receive free samples, including vouchers to exchange for free samples; types of products and top brands received; how often tobacco users received free samples; whether recipients used the free samples; whether users of the free samples like and consider purchasing products that they received as free samples; and significant predictors or factors associated with receipt. Findings will provide new information on outcomes related to the tobacco free samples ban.

Predicting Effects of ENDS Flavor Regulations on Tobacco Behavior, Toxicity, and Abuse Liability among African American Menthol Smokers

More research would be useful regarding how electronic nicotine delivery system (ENDS) uptake affects tobacco use and associated toxicity among African American (AA) cigarette smokers, particularly those who smoke menthol cigarettes. The goal of this study is to evaluate how future ENDS flavor regulations may impact African American menthol smokers. The study will evaluate whether ENDS menthol flavor availability affects measures of tobacco use, biomarkers of cigarette/ENDS exposure, and addiction among AA menthol smokers (N=210, ages ≥21) by performing a six-week clinical trial of ENDS provision with follow-up to 30 days. Specific aims are: (1) to compare the effect of ENDS flavor availability on patterns of tobacco use behavior; (2) to quantify the effect of ENDS flavor availability on biomarkers of cigarette/ENDS exposure (expired air carbon monoxide, urine cotinine/NNAL, and urine propylene glycol; and (3) to test the effect of ENDS flavor availability on addiction/abuse liability using validated behavioral economic instruments at multiple time points during the trial. Researchers will provide subjects with JUUL devices with compatible cartridges at 5% nicotine and will randomize them to one of three groups that differ by potential FDA regulations related to ENDS flavor availability: (1) the current market where only menthol- and tobacco-flavored ENDS cartridges are available; (2) a market where only tobacco-flavored ENDS are available, and (3) a market where only unflavored cartridges are available. Study visits will occur weekly beginning one week prior to randomization with daily tobacco use monitoring throughout and biomarker/self-report data collection at each in-person visit. Study results may clarify the impact on AA menthol smokers of moving from the current regulatory market where menthol/tobacco-flavored ENDS cartridges are available, to one where only tobacco or unflavored cartridges are available.

The Effect of Sweet Flavoring on the Rewarding and Reinforcing Value of Cigarillo Use Among Young Adults

Data on the impact of sweet flavoring on combustible cigarillo use is important for understanding their health impact among young adults. The study aim is to determine whether the subjective rewarding value, the relative reinforcing value, and the absolute reinforcing value of sweet-flavored cigarillos are greater than that of non-flavored cigarillos among young adults. Researchers will investigate these aims in three separate laboratory visits among 86 young adults (ages 18-24 years) who have smoked at least 10 cigarillos in their lifetime. Participants will complete various validated scale measurements, a behavioral choice task, and an ad-libitum smoking procedure. Researchers will examine whether indices of abuse liability remain significant while controlling for other factors that may underlie the preference for flavoring. Results may inform future regulatory activities related to cigarillos.

The Effects of IQOS Use on Cigarette Smoking Behavior

In 2019, the Food and Drug Administration (FDA) authorized the sale of IQOS, and more data on the impact of IQOS use on cigarette smoking behaviors would be useful. This study addresses two aims: (1) to evaluate the effects of IQOS use on cigarette smoking behaviors; and (2) to examine which subjective and objective effects of IQOS predict cigarette smoking. Researchers will recruit 100 combustible cigarette smokers ages (18-65) to a 21-day study. Baseline smoking rate will be established during days 1-5. After overnight cigarette smoking abstinence, laboratory visits on days 6 and 7 will assess IQOS-associated craving relief, withdrawal relief, risk perceptions, subjective reward, and the reinforcing value of IQOS relative to combustible cigarettes. Participants will switch from cigarette smoking to IQOS use for the following 14 days (days 8-21). Participants will collect their spent cigarette filters and their used IQOS HeatSticks daily to enable researchers to assess consumption of cigarettes and tobacco sticks per day. The primary outcome is the daily count of cigarettes from baseline to day 21, and the secondary outcome is changes in motivation to quit smoking from baseline to day 21. Findings may inform future regulatory activities related to heated tobacco products.

The Impact of Cigarillo Warnings on Purchasing and Smoking Behaviors Among Young Adult Cigarillo Users

This study will assess the effectiveness of cigarillo warnings by extending previous research in which the researchers developed pictorial warnings for cigarillos. Study aims are: (1) to examine the impact of a pictorial cigarillo warning policy on young adult cigarillo smokers’ purchasing behaviors using a behavioral economics framework; and (2) to examine the impact of repeated exposure to pictorial versus text cigarillo warnings on cigarillo smoking intentions and behaviors. Participants will be young adult frequent cigarillo users ages 21-34. An estimated 1,282 subjects (635 Black/African American and 647 White) will complete an online shopping task using the Experimental Tobacco Marketplace; researchers will then examine the impact of different cigarillo warning manipulations (pictorial, FDA text-only, Surgeon General text-only) on cigarillo purchasing, cigarillo demand, and substitution of other tobacco products. Researchers will then recruit another sample of 600 young adult frequent cigarillo users (300 Black/African American and 300 White) to participate in a 6-week randomized control trial where they will be exposed to cigarillo warnings weekly to examine the impact of the warnings on intentions to continue cigarillo smoking and cigarillo smoking behaviors. Study results may reveal how to effectively communicate the risks of cigarillo smoking to young adults, including Black/African Americans, and may inform regulatory decision-making related to cigarillo warnings.

Exosomal Epigenetic Biomarkers Associated with Flavored Electronic Cigarette Use in Adults

More information about the health risks, especially long-term health risks, of flavored e-cigarette use would be useful. The goal of this study is to identify exosomal epigenetic biomarkers (including microRNAs and long non-coding RNAs) associated with flavored e-cigarettes. Study aims are: (1) to examine blood and urinary exosomal epigenetic biomarkers and associated biological pathways related to flavored (such as fruit-flavored) e-cigarette use; and (2) to evaluate within-subject alterations in exosomal epigenetic biomarkers and associated biological pathways during e-cigarette initiation and cessation. Researchers will analyze blood and urine specimens from the Population Assessment of Tobacco and Health (PATH) Study biorepositories. After identifying key biomarkers, researchers will expose them to primary human bronchial epithelial cells and small airway epithelial cells from non-smoker adults to determine their toxicity/inflammatory response. Findings may inform future regulatory activities related to flavored e-cigarettes.

Impact of E-Cigarette Characteristics and Marketing on Tobacco Use and Health: A Longitudinal Study Among U.S. Youth and Adults

More information about the impact of e-cigarette characteristics and marketing on tobacco use among youth and adults would be useful. Researchers will analyze longitudinal data (Waves 1-4) from the Population Assessment of Tobacco and Health (PATH) Study to accomplish three study aims: (1) to identify the impact of e-cigarette flavors (non-tobacco and non-menthol flavors vs. tobacco and menthol flavors) and types (open vs. closed system) on e-cigarette use among youth (12-17 years), young adults (18-34 years), and older adults (35 years and older); (2) to determine the impact of e-cigarette advertising exposure on e-cigarette initiation, use frequency, and susceptibility, as well as the mediating effect of harm and addiction perceptions; and (3) to identify the effect of e-cigarette use on cardiovascular, respiratory, and periodontal health, and compare the effects among different types of tobacco users (e.g., exclusive e-cigarette users, never cigarette smokers, exclusive e-cigarette users, former cigarette smokers, dual users, cigarette-only smokers). Findings may impact future regulatory activities related to e-cigarettes.

The Effects of Branded and Influencer Social Media Promotion of Flavored Tobacco Products (FTP) on FTP Use Among Youth and Young Adults

This study will examine the impact of exposure to social media marketing of flavored tobacco products (FTPs). Study aims are: (1) to identify and characterize social media message content related to FTPs by source (e.g., brand, influencer/community, regular consumer) and major themes (e.g., new-user targeting, health risks, flavor-type); (2) to examine the impact of exposure to commercial and influencer FTP content on product sales and on youth and young adult awareness, risk perceptions, intentions to use, initiation, and patterns of use of FTP products; and (3) to study whether/to what extent FTP regulatory policies modify the impact of exposure to social media content on FTP product sales and youth and young adult awareness, risk perceptions, intentions to use, initiation, and patterns of use of FTP products. These aims will be accomplished by analyzing social media data from Twitter and Instagram; individual-level data on exposure to tobacco marketing, tobacco attitudes, and tobacco use from the Population Assessment of Tobacco and Health (PATH) Study; FTP sales volume data from Nielsen store scanner data; and state/local FTP policy data collected by the National Opinion Research Center. Findings from this study may inform future regulatory activities related to social media marketing of FTPs.

Racial Disparities in Biomarkers, Tobacco Cessation, and Smoking Relapse in Association with Electronic Cigarette Use

Biomarkers can play an important role in assessing the potential health effects of tobacco products. However, evidence on the racial disparities related to biomarker outcomes of e-cigarette use is scarce. The goal of this study is to examine the racial disparities in biomarkers of exposure and toxicants in association with e-cigarette use by analyzing Population Assessment of Tobacco and Health (PATH) Wave 1-4 biomarker data. Study aims are: (1) to assess racial disparities in biomarkers of tobacco exposure and toxicants; and (2) to develop a bio-socio-psycho risk score in prediction of cessation, relapse, and health outcomes. To achieve Aim 1, researchers will link the biomarker data with the PATH adult surveys to identify the between-person and within-person differences in biomarkers by use of different vaping products, flavors, and transitions between e-cigarettes and combustible cigarettes across different waves. To achieve Aim 2, researchers will then use machine learning algorithms to develop a composite bio(biomarker)-socio(socio-demographics)-psycho(psychosocial factors) risk index score for each racial/ethnic group to predict subsequent abstinence from cigarette smoking and relapse to cigarette smoking. Study findings will provide new information related to racial disparities in e-cigarette health effects.

Electronic Cigarette Use During Pregnancy and the Impact on Newborn Metabolic Profile and Perinatal Health Outcomes

More information about the effects of e-cigarette use by pregnant women would be useful. The goal of this study is to evaluate the potential adverse effects of e-cigarettes on pregnant women and their developing fetuses. Specific study aims are: (1) to determine the pattern of women’s smoking from preconception to the perinatal period; (2) to determine the pattern of women’s smoking from 2016 to 2018; (3) to determine whether pregnancy e-cigarette use is associated with pregnancy, perinatal, and infant-related adverse outcomes; and (4) to determine whether pregnancy e-cigarette use is associated with an imbalanced metabolic profile in infants measured at birth. Researchers will conduct a surveillance study of women who had live births between 2016-2018 and participated in the Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Data analyzed will include detailed smoking information, including conventional cigarette and e-cigarette use during preconception, third trimester of pregnancy, and post-delivery; researchers will also link PRAMS subjects from Tennessee and Iowa to newborn metabolic screening data to identify and validate metabolic profiles measured at birth that are associated with secondhand in utero e-cigarette and conventional cigarette exposure. Study findings may inform future regulatory activities that impact pregnant e-cigarette users.

Assessing the Impacts of the Four 2019/2020 US Federal-Level Tobacco Control Actions: Flavors, Youth Marketing, Youth Access, and Tobacco 21

Four key federal-level tobacco control actions were taken in the U.S. in December 2019/January 2020 to reduce electronic nicotine delivery system (ENDS)/tobacco use appeal and access, particularly among young people. These four actions were: (1) ENDS Flavors/Device Guidance, in which FDA prioritized enforcement against “any flavored, cartridge-based ENDS product (other than a tobacco- or menthol-flavored ENDS product),” (2) ENDS Marketing Guidance, in which FDA prioritized enforcement against “any ENDS product that is targeted to minors or whose marketing is likely to promote use of ENDS by minors,” (3) ENDS Access Guidance, in which FDA prioritized enforcement against “all other ENDS products for which the manufacturer has failed to take (or is failing to take) adequate measures to prevent minors’ access,” and (4) Federal T21, in which the federal minimum age of sale of tobacco products was raised from 18 to 21 years. Around the same time, two national public health events occurred that likely also contributed to population-level changes in ENDS/tobacco use behaviors: an outbreak of ENDS/vaping-associated lung injury (EVALI) was identified by CDC in August 2019, and the spread of a novel coronavirus in the US in January 2020 (COVID19). The shared historical timing of these actions and events requires innovative methods to assess the specific impacts of each federal action. Researchers will use a theoretically grounded mediational model to disentangle overall impacts into action-specific impacts. They will conduct secondary data analyses using the following sources: two complementary nationally-representative data sources, which each assess key measures of appeal and access and together include over 61,000 participants; the Population Assessment of Tobacco and Health (PATH) Study youth and adult surveys (2017-2021); and the U.S. arm of the International Tobacco Control (ITC) Project youth and adult surveys (2018-2021). Study findings will contribute to an understanding of the impacts of each action on Americans’ ENDS/tobacco use behaviors.

Testing the Effect of Anti-Tobacco Message Framing on Polytobacco Use in Lesbian, Gay, Bisexual, and Transgender Young Adults

Polytobacco use, defined as concurrent use of more than one tobacco product including electronic nicotine delivery systems (ENDS), is rising in lesbian, gay, bisexual, and transgender (LGBT) young adults. More information about how to effectively frame polytobacco risk communications for this population would be useful. The goal of this study is to test the effect of polytobacco message framing on risk perceptions and polytobacco use in LGBT young adults. Study aims are: (1) to identify polytobacco risk messages that effectively communicate absolute and relative risks to young adults; (2) to determine the effects of cultural targeting on LGBT young adult polytobacco users’ attention to messages and perceived effectiveness; (3a) to assess the feasibility of polytobacco risk messages developed in Aims 1 and 2 to LGBT young adults via text; and (3b) to estimate the effect sizes of exposure to messages on risk perceptions and tobacco use over time. Researchers will develop 48 messages and will conduct an online survey study with 2400 young adults (ages 18-35, estimated 50% LGBT) in which each participant will view and rate eight polytobacco education messages. Researchers will also conduct an in-laboratory study and focus groups (108 and 24-32 participants, respectively) and a Phase I randomized controlled trial (300 participants) to determine the message framing and targeting most effective for LGBT young adults. Findings may inform future tobacco education campaigns targeted to LGBT young adults.

Pharmacokinetic Bridging Study for the Inhalation of Nicotine in Saline in Male Sprague-Dawley Rats

Additional information on nicotine pharmacokinetics (PK) following inhalation will be useful in accurately predicting its PK across species (i.e., rodents, non-human primates, and humans). The CTP-NCTR InhaleCore Group has recently completed studies evaluating nicotine PK profiles in rats following a single dose administration by inhalation, oral gavage, and intravenous injection (E07607.01 and E07716.01). In these studies, the dose formulations for inhalation exposure consisted of nicotine in propylene glycol and water. Due to possible unknown inhalation toxicities of propylene glycol and its potential to impact the lungs, propylene glycol is probably not an appropriate vehicle for investigating nicotine inhalation toxicity in planned subacute and subchronic inhalation toxicology studies. In this study, the InhaleCore Group will assess the applicability of the previously collected PK data (nicotine in propylene glycol and water) to the PK profiles for new nicotine formulations (nicotine in saline) that will be used in the planned studies. Results from these studies will provide useful information for the development of physiologically-based pharmacokinetic (PBPK) modeling to characterize the PK of nicotine and its metabolites (cotinine and 3-hydroxycotinine) in rodents across different routes of exposure.

Uptake and Patterns of Use of the IQOS Heated Tobacco System by US Smokers

More information about the U.S. population health impact of IQOS, a heated tobacco system, would be useful. The goal of this project is to provide postmarket data evaluating the sociodemographic and tobacco use patterns of IQOS initiators, including the extent to which adult smokers are completely stopping use of all tobacco products, switching to exclusive IQOS use, dual-using cigarettes and IQOS, or rejecting IQOS and continuing smoking, as well as differing perceptions and use of IQOS by sociodemographic variables relevant to tobacco disparities. Study aims are: (1) to examine the sociodemographic and tobacco use characteristics, decision-making processes, and marketing exposure among adult initiators of IQOS; and (2) to examine the longitudinal determinants of long-term tobacco use outcomes among adult cigarette smokers who purchased and initiated use of IQOS. The study will involve an initial survey of 1000 adult (ages ≥18) IQOS initial purchasers and follow-up surveys of 600 cigarette smokers initially surveyed; follow-up will occur at 1 month, 6 months, and 12 months. A subsequent focus group study of 20 survey participants who had either switched to exclusive IQOS use or were dual-using IQOS and cigarettes will be conducted to obtain a deeper understanding of the quantitative findings. Findings will reveal important information about heated tobacco product use in the U.S.

Smoking Machine Adaptor Design Project for ENDS, Cigars, and Heated Tobacco Product

A single standardized smoking machine adaptor for cigars, ENDS, and heated tobacco products does not exist, making it difficult to accurately quantify the aerosol and smoke physical properties and hazardous and potentially hazardous constituent (HPHC) levels produced by these products. This design project has four aims: (1) to develop a single universal adaptor, or standardized family of adaptors, for the attachment of ENDS, cigars, and heated tobacco products to existing smoking machines originally designed for use with cigarettes; (2) to ensure that the adaptor(s) have high repeatability and reproducibility; (3) to coordinate and administer a study that tests repeatability and device validation while comparing the newly designed adaptor(s) to currently available adaptors; and (4) to provide tobacco product stakeholders with continued adaptor product support and improvement. A well-validated standardized smoking machine adaptor will ensure that accurate data are being used by stakeholders in their efforts to protect the public from tobacco-related death and disease.

Waterpipe Tobacco Additives and Their Effect on Human Puffing Behavior, Toxicant Exposures, Pulmonary Function and Appeal

Sweetened waterpipe (WP) tobacco may increase WP smoking appeal for first-time users; furthermore, high levels of sweet additives produce harmful and potentially harmful constituents (HPHCs) in WP smoke. The goal of this study is to define the effects of WP tobacco’s primary chemical additives with respect to sweet perception, appeal, toxicant exposure, addictiveness, harm and health risk perceptions, and lung function. Study aims are: (1) to characterize the HPHC and sugar content of four WP tobaccos (one brand prepared four different ways to vary glycerol and sugars); (2) to characterize the HPHC and sugar yields in mainstream smoke generated from machine smoking the four WP tobacco preparations using a research-grade waterpipe and a standardized WP puffing regimen; (3) to determine how WP tobacco content impacts puffing behaviors, a carbon monoxide biomarker, pulmonary function, nicotine uptake, and perceived sensory attributes and appeal of WP smoking, based on data gathered from 50 experienced WP smokers (ages 21-50) who will smoke the four different WP tobacco preparations in four different laboratory sessions; and (4) to determine the HPHC exposure ranges from the average puffing behaviors measured under Aim 2 for each WP tobacco preparation. Findings will provide new information about the impact of chemical additives in WP tobacco.

Understanding Uncontrolled Vaping Among Vulnerable Populations

E-cigarettes differ from combustible cigarettes in ways that may make it harder to control vaping. For example, e-cigarettes lack many of the same stopping cues as cigarettes, indoor bans are less common, and discreet use is easy. The goal of this study is to understand uncontrolled vaping and vaping restraint strategies. Study aims are: (1) to develop measures of uncontrolled vaping and restraint strategies; (2) to assess prevalence of and factors related to both uncontrolled vaping and restraint strategies; and (3) to establish the long-term impact of vaping restraint on uncontrolled vaping. To achieve Aim 1, researchers will conduct phone interviews with 8 adolescent (ages 13-17), 8 young adult (ages 18-25), and 8 adult (ages 26 and older) current e-cigarette users to understand how they describe uncontrolled use and vaping restraint and will then develop survey measures. To achieve Aim 2, researchers will survey 1,050 current e-cigarette users (300 adolescents, 300 young adults, and 450 adults) and evaluate the usefulness of the new measures. Researchers will then estimate uncontrolled use and vaping restraint strategies for the nation and examine whether these outcomes are more common among vulnerable populations, certain device type users, and dual users. To achieve Aim 3, researchers will conduct a follow-up online survey with approximately 700 e-cigarette users from the Aim 2 sample to examine how baseline vaping restraint related to uncontrolled vaping and smoking behavior one year later. Findings may inform regulatory activities related to e-cigarettes.

The Impact of Cigar Pack Quantity on Tobacco Use Behaviors

The goal of the proposed analyses is to clarify the relationship between cigar pack quantity and tobacco use behaviors. Study aims are: (1) to determine whether cigar pack quantity is associated with between- or within-person changes in cigar use and assess whether changes vary by sociodemographic characteristics (age, sex, race, ethnicity, income, and educational attainment); (2) to evaluate the impact of minimum cigar pack quantity laws on tobacco use and assess whether the impact of these laws varies by sociodemographic characteristics; (3) to evaluate the impact of minimum cigar pack quantity laws on cigar sales and assess whether the impact of these laws varies by county characteristics; and (4) to characterize differences in implementation and enforcement of minimum cigar pack quantity laws through qualitative interviews with key implementation personnel. The researcher will analyze data from national datasets, including the Population Assessment of Tobacco and Health (PATH) Study, the Tobacco Use Supplement to the Current Population Survey (TUS-CPS), the Youth Risk Behavior Surveillance System (YRBSS), and Nielsen retail scanner data. Study findings may inform future regulatory activities related to cigar pack quantity.

Designing and Evaluating Communication for Dual Users of E-cigarettes and Combustible Cigarettes

People who use both cigarettes and e-cigarettes (“dual users”) may not be adequately informed of their continued risk from smoking combustible cigarettes as well as the known harms of e-cigarettes. The goal of this project is to develop communication campaign messages for dual users that increase their knowledge of the high health risk of dual use and increase their intent to quit combustible cigarettes and ultimately e-cigarettes. Study aims are: (1) to develop effective campaign messages by investigating how dual users think about their identity, motivations for tobacco product use, and the barriers to quitting combustible cigarettes; (2) to determine whether campaign ads are more engaging if they focus on quitting combustible cigarettes only, sequentially quitting cigarettes and e-cigarettes, or simultaneously quitting cigarettes and e-cigarettes; and (3) to pilot test the effectiveness of texted campaign ads in changing real-world combustible cigarette and e-cigarette quit intention among dual users. To achieve Aim 1, the research team will conduct six focus groups (8-10 adult dual users ages 18+ per group) to better understand dual use and gather concepts for messages, draft 50-75 potential campaign messages for dual users to encourage them to quit, and conduct a national survey with 1,008 adult dual users to select the most promising campaign message themes. To achieve Aim 2, the team will create visual ads for the messages from Aim 1 and use an eye-tracking experiment to determine how the different conditions affect attention among dual users. To achieve Aim 3, the team will conduct a five-week experiment with 90 adult dual users randomized to receive the most effective ads from Aim 2 or control ads in order to determine subsequent quit intentions and behaviors. Study findings may inform the development of communication campaign messages specifically for dual cigarette and e-cigarette users.

Patterns of Use and Health Effects of “Premium Cigars” and Priority Research

Patterns of use can vary widely across cigar subtypes both by frequency of use and the population subgroups most likely to use them. Some research indicates that “premium” cigar smokers (versus smokers of other cigar subtypes) are significantly less likely to use cigars regularly (daily or monthly) or report current cigarette smoking. Still, all cigars pose serious negative health risks and premium cigars are used by youth and young adults. The goal of this study is to conduct an in-depth evaluation of the public health issues related to premium cigars (defined in this study as large cigars that contain tightly rolled tobacco wrapped in a tobacco leaf) as well as the health effects of premium cigars compared to other cigars and other tobacco products. This study will involve a comprehensive and systematic review and assessment of the scientific literature related to premium cigars. Topics evaluated will include patterns of use of premium cigars; how use patterns differ among cigar subtypes and other tobacco products and among different populations (types of tobacco users, age groups, and other demographics); and the short- and long-term health effects of premium cigar use. Findings may inform future regulatory activities related to premium cigars.

Chronic Hookah (Waterpipe) Smoking, Vascular Dysfunction, Inflammation and Oxidative Stress

The goal of this research is to clarify the long-term health effects of hookah (waterpipe) smoking on endothelial (artery lining) and vascular (blood vessel) function and identify biomarkers of harm that are associated with the effects of chronic hookah smoking on vascular health. Study aims are: (1) to evaluate the chronic effects of hookah smoking on peripheral endothelial function; (2) to study the chronic effects of hookah smoking on central artery stiffness; and (3) to evaluate the chronic effects of hookah smoking on biological markers of oxidative stress and inflammation. In 34 healthy chronic hookah smokers (ages 21-49 years) who never smoked cigarettes, matched for age and sex with 34 cigarette smokers and 34 non/never-smokers, researchers will measure: (a) endothelial function (measured by brachial artery flow-mediated dilation); and (b) vascular stiffness (measured by carotid-femoral pulse wave velocity and aortic augmentation index). Biological markers of inflammation (high sensitivity C-reactive protein, 8-iso-prostaglandin F2a, fibrinogen) and oxidative stress (pro-oxidant high density lipoprotein oxidant index and total antioxidant capacity) will be collected. Findings will provide new information about the chronic effects of hookah smoking and provide a foundation for future long-term studies of the effects of hookah smoking.

The Effect of Switching on or off Menthol Use on Cigarette Consumption, Dependence, Nicotine Exposure and Quitting Success

More information about menthol use among subpopulations would be useful. Researchers will analyze data from the adult (ages 18+) sample of cigarette smokers in Waves 1-4 of the Population Assessment of Tobacco and Health (PATH) Study using a technique called propensity score matching. They will study two groups of adult smokers: smokers who switched from menthol to non-menthol cigarettes and later attempted to quit smoking, and smokers who switched from non-menthol to menthol cigarettes and later attempted to quit smoking. Study aims are: (1) to compare quitting success between quit attempters who switched from menthol to non-menthol cigarettes and those who switched from non-menthol to menthol cigarettes; (2) to compare consumption, nicotine exposure, and dependence between adult smokers who did not successfully quit after either switching from menthol to non-menthol cigarettes or switching from non-menthol to menthol cigarettes; and (3) to assess whether race, sex or age modify the effect of switching from menthol to non-menthol cigarettes or from non-menthol to menthol cigarettes on 30-day cigarette abstinence, 12-month cigarette abstinence, consumption, dependence, and nicotine exposure. Study findings may inform future regulatory activities related to menthol.

Distinguishing Exposure to Secondhand and Thirdhand Tobacco Smoke and Electronic Cigarettes among U.S. Children Based on Multiple Biomarker Profiles

Currently, tobacco smoke exposure biomarkers that differentiate exposure to thirdhand smoke (THS) from exposure to secondhand smoke (SHS) or e-cigarette aerosol exposure are lacking. The goal of this project is to examine existing tobacco-specific and nonspecific biomarkers to assess children’s exposure to diverse tobacco/nicotine products. Researchers will analyze National Health and Nutrition Examination Survey (NHANES) 2013-2016 data to examine the prevalence and health risks of exposure to SHS and THS among children presumed to be unexposed to any tobacco smoke and among children exposed to e-cigarette aerosol only. This project has three study aims. Aim 1 is to compare tobacco-specific biomarkers of exposure (e.g., cotinine, total nicotine equivalents, tobacco-specific nitrosamines) with self-reported smoking and tobacco smoke exposure to categorize children into one of four groups: (a) mixed SHS and THS group (MEG): lives with nonsmokers or smokers of combustible products only, reported SHS; (b) THS group (TEG): lives with nonsmokers or smokers, no reported SHS; (c) e-cigarette group (ECG): lives with e-cigarette only users, reported e-cigarette aerosol exposure; and (d) no/minimal exposure group (NEG): lives with nonsmokers, no reported SHS. Aim 2 is to examine multiple tobacco-nonspecific (i.e., polyaromatic hydrocarbons, volatile organic compounds) and tobacco-specific biomarkers and biomarker ratios (e.g., NNAL/cotinine, 2-hydroxyfluorene/cotinine) to assess which combination of biomarker profiles further differentiates children by exposure type. Aim 3 is to examine the associations between exposure type and demographics, exposure-related symptoms, diagnoses, and healthcare utilization patterns in the MEG, TEG, and ECG compared with the NEG. Study findings will provide insight into the different health effects children experience depending on type of tobacco product exposure.

CTP Supplement to Parent Grant: Yale Center for the Study of Tobacco Product Use and Addiction: Flavors, Nicotine, and Other Constituents (YCSTP) (TCORS 2.0)

This supplement project will measure the effects of e-cigarette use and abstinence on the adolescent brain and behavior by testing biomarkers to assess short- and long-term e-cigarette effects. This project will add neuroimaging and neurocognitive testing to an existing clinical trial of an e-cigarette cessation intervention in adolescents (Yale’s Adolescent Brain Cognitive Development [ABCD] study); it will use ABCD neuroimaging and neurocognitive testing protocols to investigate how critical domains of function (i.e., reward processing, impulsivity and impulse control, working memory, emotion regulation) differ among adolescent e-cigarette users and change with abstinence. All youth in the trial (N=100; ages 13-20) will complete the ABCD neurocognitive battery, and 30 youth in the trial and 30 age/sex-matched controls will complete the ABCD neuroimaging protocol. Specific aims are: (1) to test for baseline brain and behavioral differences in critical domains of function between youth e-cigarette users and non-users; (2) to compare changes in brain and behavioral measures of critical domains of function between youth e-cigarette users and non-users; and (3) to test the relationship between changes in critical domains of function and e-cigarette abstinence among youth users. Findings will provide some of the first measures of the impact of e-cigarette use and abstinence on brain and behavior biomarkers of addiction among adolescents.

Center for the Study of Tobacco Products: Respiratory Effects of THC and Nicotine E-Cigarettes: A Prospective Study

E-cigarette/vaping-associated lung injury (EVALI) is a new disease that is not well-understood, in part because of the differences among e-cigarette devices and liquids used; however, it has been linked to tetrahydrocannabinol (THC) liquid use and vitamin E acetate inhalation. Importantly, computed tomography (CT) scans of the lungs of EVALI patients uniformly reveal “ground-glass opacities” (GGOs), which indicates partial displacement of air within the lung; the appearance of GGOs in e-cigarette users is a potential EVALI biomarker. Researchers at the Center for the Study of Tobacco Products (CSTP) will perform CT scans and pulmonary function tests and analyze the devices and liquids from healthy e-cigarette users aged 18-45 years. They will track participants’ respiratory health for two years and then conduct a second set of CTs and pulmonary function tests. Study aims are: (1) to perform CT scans and pulmonary function tests at baseline and after two years on 45 exclusive nicotine e-cigarette users, 45 exclusive THC e-cigarette users, and 45 nicotine+THC e-cigarette users, as well as an additional 45 non-e-cigarette users as controls; (2) to identify e-cigarette devices and analyze e-cigarette liquids used by each participant; and (3) to track respiratory health over two years using quarterly online surveys assessing respiratory and gastrointestinal symptoms. Study findings may provide more information about EVALI and may inform future regulatory activities related to e-cigarettes.

Pilot Study to Determine Health Effects of E-cigarettes in Healthy Young Adults

In this CTP supplement to a parent grant (Integrated Translational Health Research Institute of Virginia (iThriv): Using Data to Improve Health), researchers will conduct studies to assess early changes in human lungs due to e-cigarette use. This study will use a new magnetic resonance imaging technique called 3-dimensional hyperpolarized xenon-129 MRI. It is anticipated that this new MRI technique will help detect possible early changes in the lungs of healthy young people who use e-cigarettes. Study aims are: (1) to determine effects of e-cigarette use on healthy young adults (ages 21-30) who have never smoked cigarettes, and (2) to develop research methods to perform a larger clinical trial to determine whether e-cigarettes cause lung disease, and if so, what kind. To achieve the first aim, researchers will study ten e-cigarette users with normal lung function tests and ten healthy non-users. Researchers will perform MRI tests and collect exhaled breath, blood, and urine for testing. To achieve the second aim, researchers will develop study methods for performing MRIs at two locations, the University of Virginia and Duke University, in preparation for a multi-center clinical trial to conclusively determine if there are harmful health effects of e-cigarettes. Study results will provide new knowledge on the impact of e-cigarettes on human lung health.

Yale Center for the Study of Tobacco Product Use and Addiction: Flavors, Nicotine and Other Constituents

To reduce the risk of e-cigarette/vaping acute lung injury (EVALI), several states have banned flavored e-cigarette sales and one temporarily banned all vaping product sales. In this CTP supplement to a parent grant (Yale Center for the Study of Tobacco Product Use and Addiction), researchers will use new data from e-cigarette/vaping acute lung injury (EVALI) case reports by state and by month to estimate how smoking and vaping rates shifted in response to these policies as well as to the EVALI outbreak itself. Study aims are: (1) to clarify how state variation in behaviors and policies may have contributed to EVALI’s geographic distribution; (2) to quantify changes in vaping and smoking rates in response to the EVALI outbreak; and (3) to estimate how states’ policy responses to EVALI affected vaping and smoking. To address Aim 1, researchers will conduct analyses to characterize states’ 2019 EVALI prevalence by their pre-outbreak rates of vaping and marijuana use as well as marijuana legalization policies. To address Aim 2, researchers will analyze how adults’ smoking and vaping behavior shifted following changes in their state’s reported EVALI prevalence. To address Aim 3, researchers will estimate how banning flavored e-cigarette sales and all vaping product sales affected smoking and vaping rates (before and after policy implementation and compared to states that did not adopt policies). Study findings may inform state regulatory activities related to e-cigarettes.

Secondhand E-cigarette Exposure and Lung Function in Children

In this CTP Supplement to a parent grant about how lifetime environmental exposures impact health (the HERCULES Exposome Research Center), researchers will describe secondhand e-cigarette aerosol exposure and measures of lung function in children (ages 6-12) who reside with daily vapers. Study aims are: (1) to examine associations between secondhand e-cigarette aerosol chemical exposures and salivary metabolic profiles and pathways, and (2) to examine associations of secondhand e-cigarette chemical exposure and salivary metabolic profiles with markers of lung function. To achieve Aim 1, researchers will measure nicotine, benzene, and toluene exposure in 30 children of daily vapers and 30 children of non-vapers/non-smokers who will wear wristband air samplers for 120 hours (5 days). Researchers will collect saliva samples and analyze them to identify altered metabolic profiles and pathways; they will also examine associations of nicotine, benzene, and toluene with salivary metabolic profiles. To achieve Aim 2, researchers will examine associations between nicotine, benzene, and toluene exposure data and metabolomics data (from Aim 1) and lung function measures including fractional exhaled nitric oxide (FeNO), forced expiratory volume in one second (FEV1), forced vital capacity (FVC), mid-expiration forced expiratory flow rate (FEF 25-75%), and parent report of recurrent/chronic respiratory symptoms. Study findings may inform future regulatory activities related to e-cigarettes.

Understanding the Influence of E-cigarette Advertisement Features

The goal of this study is to examine the influence of four e-cigarette advertisement features (flavors, models, marketing claims, and price promotions) on young adult (ages 18-29) non-tobacco users who are susceptible to e-cigarette use. Study aims are: (1) to identify key features of e-cigarette advertisements that lead to greater attention; (2) to examine the associations between key features of e-cigarette advertisements and positive neurocognitive responses; and (3) to determine whether edited advertisements without key features lead to reduced positive e-cigarette perceptions and behavioral intentions compared to original advertisements. To address Aim 1, researchers will use eye-tracking technology to identify key e-cigarette advertisement features that receive attention (gaze duration and fixation frequency) in 70 young adults. To address Aim 2, researchers will use electroencephalogram (EEG) technology to evaluate the associations between key e-cigarette advertisement features and sustained cognitive processing and emotional arousal in 120 young adults. To address Aim 3, researchers will conduct a randomized comparative study among 900 young adults to determine whether an intervention group that receives e-cigarette advertisements without key features has lower levels of positive e-cigarette perceptions and behavioral intentions than a control group that receives original unaltered advertisements. Findings will provide information about the potential impact of specific e-cigarette advertising characteristics on the initiation and progression of e-cigarette use among young adults.

The Relationship Between Nicotine Metabolism and Nicotine Concentrations in E-cigarettes on Smoking Behavior and Toxicant Exposure in African American and White Smokers

African Americans are particularly vulnerable to smoking-related diseases and are less successful at smoking cessation. The goal of this study is to investigate the use of e-cigarettes for smoking reduction in African American and White smokers. Study aims are: (1) to investigate the impact of nicotine metabolism on nicotine pharmacokinetics and the subjective effects of nicotine concentrations in e-cigarettes, and (2) to elucidate the relationship between nicotine metabolism and nicotine concentrations in e-cigarettes and the impact on smoking behavior and toxicant exposure. To address Aim 1, 56 smokers (28 African American subjects and 28 White subjects ages 18 and older) will receive e-cigarettes with their preferred flavor (menthol or tobacco) and 10mg/ml and 50mg/ml of nicotine during two sessions (one concentration per session). To address Aim 2, one week after the completion of Aim 1, subjects will receive preferred-flavor e-cigarettes with 10mg/ml or 50mg/ml of nicotine to take home for two weeks. Outcomes (and associated race differences) for these study aims will include nicotine metabolite rate, plasma nicotine levels, carbon monoxide, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), cigarette craving, nicotine withdrawal, nicotine dependence, cardiovascular and lung function, volatile organic compounds, self-reports of combustible tobacco product use, e-cigarette use, and amount of e-liquid used. Study findings will help elucidate the relationship between nicotine metabolism and e-cigarette nicotine concentration and its impact on smoking behavior and toxicant exposure in African American and White smokers.

Neuroimaging Approaches to Improve Prediction of Smoking Initiation and Nicotine Use Escalation Among Young Adult Electronic Nicotine Delivery Systems Users

The goal of this study is to identify neurobehavioral markers of nicotine use escalation and cigarette smoking initiation among young adult electronic nicotine delivery systems (ENDS) users. Study aims are: (1) to identify neural and behavioral markers of ENDS escalation and smoking initiation; (2) to determine whether neural markers add predictive utility beyond traditional measures; and (3) to determine the efficacy of public service announcements (PSAs) and identify neural predictors of PSA efficacy. At baseline, the researcher will measure traditional behavioral and novel brain responses using functional MRI in 180 non-smoking young adult (age 18-20) ENDS users to identify salient predictors of nicotine use escalation and smoking initiation; the researcher will quantify responses to smoking stimuli, vaping stimuli, and associated food stimuli in brain systems associated with cognitive control, emotion, and salience. Responses in the same brain networks will be assessed in response to existing tobacco control education PSAs and PSAs addressing ENDS flavors. Over the following six months, participants will receive weekly PSAs and bi-weekly PSA evaluations via emails and texts. In addition to evaluating the PSAs, participants will report all tobacco product use during the past two weeks. In-person visits at 3, 6, 9 and 12 months will include breath carbon monoxide and urine cotinine tests. Outcomes will include cigarettes smoked, exhaled carbon monoxide levels, urine cotinine levels, and ENDS and tobacco use outcomes. Study findings may inform future regulatory activities related to ENDS.

Novel Methods for Evaluating the Association of Electronic Cigarette Use with Cardiovascular Health

The goal of this study is to provide population-based evidence on the cardiovascular (CV) effects of e-cigarette use, including particular e-cigarette aerosol components that may be responsible for CV harm. Study aims are: (1) to examine the effects of e-cigarette use and cigarette/e-cigarette transitions on CV events; (2) to estimate associations of e-cigarette use with risk factors and preclinical biomarkers of CV injury, and to analyze biomarkers of exposure as potential mediators; and (3) to identify unique biomarker signatures of e-cigarette exposure and to associate clusters with preclinical biomarkers of CV injury. To achieve Aim 1, the researcher will use data from the Population Assessment of Tobacco and Health (PATH) Study Waves 1-4 (2013-2017) to investigate to what extent e-cigarette use is associated with CV events including myocardial infarction, stroke, and heart failure. To achieve Aim 2, the researcher will assess the effects of e-cigarette use on CV risk factors (blood pressure, triglycerides, and cholesterol) using data from the National Health and Nutrition Examination Survey (NHANES, 2013-2016) and on preclinical biomarkers of CV injury (inflammation, thrombosis, and oxidative stress) using data from PATH Wave 1 (2013-2014). To identify specific e-cigarette aerosol components that mediate CV risk, the researcher will analyze urinary exposure biomarkers for product constituents (nicotine, tobacco-specific nitrosamines [TSNAs], volatile organic compounds [VOCs], polycyclic aromatic hydrocarbons [PAHs], and metals). To achieve Aim 3, the researcher will use data from PATH Wave 1 to define clusters of e-cigarette use based on shared urinary exposure biomarker profiles related to use behaviors (frequency, other tobacco products, and reasons for use) and product characteristics (type and flavors), and associate each with preclinical biomarkers of CV injury. Study findings may inform regulatory activities related to e-cigarettes.

Development of Early Warning System for Toxins Related to EVALI and Vaping

In this CTP supplement to a parent grant (Co-Abuse of Cannabis and Tobacco), researchers will lay the foundation for developing an early warning system that identifies and evaluates emerging chemical threats posed by e-liquids that may lead to acute illnesses such as e-cigarette/vaping-associated acute lung injury (EVALI). The goal is to detect emerging trends in the composition of vaping liquids and would allow identification and evaluation of possible hazards before their use becomes widespread. Study aims are: (1) to mine social media data to identify emerging vaping products and potential hazardous constituents used in vape liquids; and (2) to analyze the aerosol properties and chemical composition of aerosolized vitamin E acetate (i.e., a chemical already suspected to be hazardous) and other potential hazardous constituents identified from social media monitoring in Aim 1 to determine their effects in lung tissue. Findings may inform future regulatory activities related to e-cigarettes.

Hispanic and Latino Youth and Tobacco Use: Foundational Research

The goal of this research effort is to guide CTP audience segmentation and communications strategies to inform evidence-based decisions about communications activities designed to prevent initiation of tobacco use among Hispanic/Latino youth and young adults. The research includes three tasks: (1) a comprehensive literature review and environmental scan, (2) secondary data analysis and audience segmentation, and (3) primary data collection among high-risk audiences. The scope and approach of the primary data collection will be informed by the first two phases and will include at least one round of qualitative data collection (e.g., focus group discussions) and may also include quantitative data collection/survey research; the number of subjects and age ranges have yet to be determined. This research will inform future CTP communications activities that are targeted toward Hispanic/Latino youth.

Respiratory Health and Cigar and Pipe Use in the NHLBI Pooled Cohorts Study

Cigarette smoking is the major risk factor for chronic lower respiratory disease (CLRD), which includes chronic obstructive pulmonary disease (COPD) and asthma. The goal of this study is to test whether cigar and pipe use is associated with accelerated lung function decline and CLRD-related hospitalizations and mortality. Researchers will analyze data from the National Heart, Lung, and Blood Institute (NHLBI) Pooled Cohorts Study, which collected lung function data (including spirometry exam data) from nine US general population-based cohorts that included 65,251 American Indian, Asian, Black, Hispanic and White adult men and women. Study aims are: (1) to harmonize self-reported interview questions on cigar and pipe use across the study cohorts in order to characterize cigar/pipe use; (2) to assess associations between cigar/pipe use and lung function changes over time, including rates of forced expiratory volume in one second (FEV1) decline, forced vital capacity (FVC) decline, FEV1/FVC, and airflow obstruction; and (3) to assess the association between cigar/pipe use and CLRD-related hospitalizations and mortality. Study findings may inform future regulatory activities related to cigar and pipe tobacco products.

Respiratory Effects of Exposure to Metals from Electronic Cigarettes (RE-EMIT)

Several metals, including lead and nickel, are known lung toxicants and have been found in e-cigarette aerosols. In this CTP supplement to a parent grant (The Exposure to Metals from E-Cigarettes (EMIT) Study), researchers will study how patterns of “pod” e-cigarette device use impact exposure to metals among young adults (ages 18-24) and how these metal exposures may be associated with pulmonary health effects. Study aims are: (1) to evaluate the contribution of pod devices to metal exposure; (2) to measure pod users’ pulmonary health outcomes and evaluate their association with pod use; and (3) to assess the role of metals in pod-related pulmonary health outcomes. To achieve Aim 1, researchers will assess metal concentrations in pod aerosol (collected from each participant’s device) and assess their association with use patterns (from a questionnaire) as well as established biomarkers of metal exposure in blood (lead, cadmium, manganese and zinc) and urine (nickel, arsenic, chromium, antimony, and tungsten); they will also measure chromium and arsenic in the aerosol. To achieve Aim 2, researchers will characterize differences in pulmonary outcomes between pod users and non-users at 0 and 6 months; among users, researchers will evaluate differences by age, sex, and pod type. To achieve Aim 3, researchers will assess the association of metals in pods and in biomarkers of exposure (e.g., urine nickel) with measures of lung effects by evaluating which patients fall below the lower limit of normal for pulmonary function tests. Researchers will add pulmonary outcome measures to 25 pod users and 25 control participants from the parent study, and will recruit an additional 25 pod users and 25 non-users (ages 18-24) to characterize pulmonary outcomes (reductions in the forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and diffusing capacity of carbon monoxide (DLCO)), measures of metals in device aerosols, and measures of exposure to metals in urine and blood at 0 and 6 months. Study findings may inform future regulatory activities related to e-cigarettes.

Modeling Tyrosine Kinase Inhibitor-Induced Vascular Dysfunction Using Human iPSCs

Additional information about the pulmonary health effects of e-cigarettes would be useful, particularly given the growing number of e-cigarette or vaping use-associated lung injury (EVALI) cases. In this CTP Supplement to a parent grant (Modeling Tyrosine Kinase Inhibitor-Induced Vascular Dysfunction Using Human iPSCs), researchers will use a human induced pluripotent stem cell (iPSC)-based in vitro pulmonary toxicity screen to investigate the cellular, molecular, and genomic effects of six common e-cigarette components on lung tissue. Study aims are: (1) to generate iPSC-derived lung cells (i.e., alveolar epithelial cells, fibroblasts, smooth muscle cells, endothelial cells) from 12 existing healthy iPSC lines (6 male/6 female); and (2) to investigate the effects of e-cigarette components implicated in EVALI, including vitamin E acetate, tetrahydrocannabinol (THC), nicotine, propylene glycol, vegetable glycerin, and cannabidiol (CBD). Study findings may lead to new biomarkers and may inform future regulatory activities related to e-cigarettes.

Cigarette Smoking as a Risk Factor for Greater Psychiatric Symptom Severity Across Serious Mental Illnesses: A Secondary Analysis of Three Nationally-Representative NIH Datasets

People with serious mental illnesses (SMIs) such as bipolar disorder (BD), schizophrenia (SCZ), and major depressive disorder (MDD) comprise a population that is especially vulnerable to tobacco use; people with SMIs are twice as likely to smoke as people without SMIs. However, a federal tobacco education campaign targeted to the SMI subpopulation has not yet been developed. The goal of this study is to provide scientific evidence that could be used to develop such a campaign. Specific aims are: (1) to determine whether smoking is a risk factor for increased time in illness episodes (mood episodes in BD smokers; psychotic episodes in SCZ smokers; and depressive episodes in MDD smokers) in people with SMIs; (2) to determine whether smoking is a risk factor for increased time in depression across SMIs; and (3) to determine predictors of within-person changes in smoking behavior (initiating, quitting, relapsing). To achieve these aims, researchers will analyze data from three large National Institutes of Health datasets (BD: STEP-BD study, N=4361; SCZ: CATIE study, N=1460; and MDD: STAR*D study, N=2248). Study findings will provide scientific evidence that may be used to inform the development of a tobacco education campaign targeted to people with SMIs.

Predicting Longitudinal Patterns of Change in Adolescent Polytobacco Use: A Socio-Ecological Framework

More information about how patterns of single and polytobacco use change from early adolescence into emerging adulthood would be useful. The goal of this project is to examine patterns of change and associated predictive factors over an extended time period. Study aims are: (1) to examine trajectories and related predictors of single tobacco product use from early adolescence (age 12) to emerging adulthood (age 23); (2) to examine transitions into and out of polytobacco use classes, as well as predictors of these classes, from early adolescence (age 12) to emerging adulthood (age 23), and (3) to examine interactions among individual (e.g., motives for use, sensation seeking), interpersonal (e.g., parent modeling, rules), and contextual (e.g., geographic location) factors in predicting trajectories of single tobacco product use and transitions in polytobacco use. Researchers will analyze Population Assessment of Tobacco and Health (PATH) Study data (total of 52,731 respondents) from study waves 1 (2013-2014), 2 (2014-2015), 3 (2015-2016) and 4 (2016-2018) to examine the changes over time in use of tobacco products (cigarettes, cigars, waterpipes, smokeless tobacco, electronic cigarettes) individually and in combination. Study findings may inform regulatory activities related to youth and young adult use of tobacco products.

Measuring Anatalline and Nicotelline to Differentiate Non-combusted Tobacco Use Using the PATH Study

Biomarkers that can distinguish between types of tobacco product use can be used to help track associated health effects. The goal of this study is to measure nicotelline, a minor tobacco alkaloid associated with tobacco smoke particulate matter, in urine biospecimens gathered during Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study. Previous research has shown that, when expressed as a ratio with its parent compound (anatalline), nicotelline may distinguish smokeless tobacco use from combusted tobacco use. Study Aim 1 will validate the anatalline/nicotelline ratio cut-points (as well as nicotelline in combination with other tobacco exposure biomarkers) that distinguish exclusive cigarette use, exclusive smokeless tobacco use, and dual smokeless plus cigarette use (140 adults each). In Study Aim 2, researchers will use the same participant groups defined in Study Aim 1 to explore whether nicotelline and ratios of nicotelline-to-traditional tobacco biomarkers (i.e., 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL]) can differentiate e-cigarette use from exclusive cigarette use using data from exclusive e-cigarette users and dual e-cigarette plus cigarette users. Study findings may confirm nicotelline’s usefulness as a biomarker to discriminate among tobacco products and to identify patterns of polytobacco use.

Tobacco Use Trajectories and Disparities Among Sexual Minorities in U.S Adolescents and Adults

Sexual minority individuals comprise a population that is particularly vulnerable to tobacco use. The goal of this project is to analyze tobacco use across time in sexual minorities and resulting tobacco-related health disparities using Population Assessment of Tobacco and Health (PATH) Study data. Of PATH respondents with valid self-reported sexual identity (gay/lesbian, bisexual, something else, or straight) at all four study waves (N=26,696, ages 12+years), 2,520 reported sexual minority identity at one wave or more; 1,474 reported sexual minority identify at wave 1; and 905 reported sexual minority identity at all four waves. Study aims are: (1) to examine tobacco product initiation and use trajectories by sexual orientation and their associations with regular tobacco use and tobacco use disorder symptoms; (2) to identify tobacco use trajectories by sexual orientation and different associations with self-reported and biological health outcomes; and (3) to examine the role of biological and psychological stress on tobacco use trajectories, tobacco cessation, and tobacco-related health outcomes among adults and how these measures differ by sexual orientation. Researchers will assess tobacco use trajectories, including tobacco use initiation; progression in the number of products used, with a focus on e-cigarette use/non-use; and increase and decrease in use frequency. Aims 2 and 3 will involve analysis of survey self-report measures of stress (psychological distress) and health outcomes (respiratory illness, cancer, cardiovascular disease) alongside biological markers of stress (e.g. C-reactive protein, interleukin-6) and tobacco-specific markers linked to cancer risk (NNAL, NNN, TNE2). Researchers will also examine important moderators including age, sex, race and ethnicity throughout in all analyses. This project will provide new data that may inform regulatory activities to address the health burden of tobacco use among sexual minorities.

Do E-Cigarette Users Airways Have an Altered Lipid Content?

In this study, researchers will use previously-collected serum, saliva, sputum, and bronchoalveolar lavage fluid (BALF) from healthy never-smokers, tobacco smokers or vapers to determine whether the airways of e-cigarette users have an altered lipid (fat) content that may cause acute lung injury. Study aims are: (1) to determine the concentrations of lipid-associated surfactant proteins in samples of BALF, sputum and saliva from non-smokers, smokers and vapers; (2) to measure lung cell lipid content and stain alveolar macrophages (a type of white blood cell in the lung) with Oil Red O to look for altered lipid content in vapers’ alveolar macrophages and airway secretions; and (3) to study metabolites on samples of BALF, sputum and saliva from non-smokers, smokers and vapers. To achieve Aim 1, researchers will use western blotting techniques to determine the amounts of lipid-associated surfactant proteins in vapers’ airway secretions. To achieve Aim 2, researchers will use mass spectrometry as well as standard histological techniques to better understand the impact of lipid accumulation on vapers’ lungs. To achieve Aim 3, researchers will use mass spectrometry to determine levels of nicotine, cotinine, tetrahydrocannabinol (THC), and metabolites that are associated with lung injury in vapers’, non-smokers’, and smokers’ lungs. Findings may inform future regulatory activities related to e-cigarettes.

Do E-cigarette Design Features Impact Cigarette Initiation, Cessation & Relapse?

More information about how e-cigarette characteristics impact transitions to and from cigarette smoking would be useful. This project will evaluate the independent effects of four e-cigarette design features (flavors, device type, nicotine content, and nicotine formulation) on later cigarette smoking initiation, cessation, and relapse among youth (ages 12-17), young adults (ages 18-24) and adults (ages 25 and older) in the U.S. Researchers will analyze data from the Population Assessment of Tobacco and Health (PATH) Study, the U.S. arm of the International Tobacco Control (ITC) Youth Tobacco and E-cigarette Survey, and the U.S. arm of the ITC Four Country Smoking and Vaping Survey. Study aims are: (1) to examine e-cigarette use and cigarette initiation among non-smoking youth and young adults, particularly whether and how e-cigarette design features predict future cigarette smoking initiation, including progression to regular cigarette smoking; (2) to examine e-cigarette use and cigarette cessation among youth and adult cigarette smokers, specifically whether and how e-cigarette design features impact later cigarette smoking cessation, considering both the potential reach and effectiveness of design features; and (3) to examine e-cigarette use and cigarette relapse among adult former cigarette smokers, specifically whether and how e-cigarette design features impact later cigarette smoking relapse. These findings may inform FDA regulatory activities related to e-cigarettes.

Derivation of Lung Epithelia from iPS cells for Advanced Disease Modeling

The goal of this CTP supplement to a parent grant (which funds the study of alveolar epithelial type 2 cells [AEC2s], a type of lung cell) is to determine the effects of e-cigarette vapor exposure on the human alveolar epithelium (the internal surface area of the lung). Researchers will use newly-developed protocols to generate human AEC2s from induced pluripotent stem cells (iPSCs). They will culture the AEC2s using an air-liquid interface method and then expose them to (1) e-cigarette vapor containing nicotine, (2) e-cigarette vapor containing vitamin E-acetate (implicated in e-cigarette/vaping acute lung injury, or EVALI), (3) cigarette smoke, or (4) air (a control condition). Researchers will then measure the effects of these exposures on the RNA molecules, proteins, and metabolites in the AEC2s and generate a dataset. Study findings will describe e-cigarette vapor injury to this key lung cell type.

CTP Supplement to Parent Grant: The Role of Histone Deacetylase 9 in Vascular Calcification

In this CTP Supplement to a parent grant studying the role of histone deacetylase 9 (HDAC9, an essential regulator of vascular function), researchers will investigate whether toxic metals from vaping products prompt HDAC9-dependent dysregulation of vascular cell function and increased inflammation. Study aims are: (1) to analyze the heavy metal profiles of aerosol vapor generated by different open-system vaping devices, and (2) to determine the effects of toxic heavy metals in vaping aerosols and e-fluids on vascular cell function in vitro and cardiovascular and pulmonary function in vivo. To achieve Aim 1, researchers will use mass spectrometry to profile metals (by element and concentration) in aerosol vapor from six different open-system vaping devices (three refillable cartridges and three tank devices) and identify the origin (e-fluid, reservoir, heating coil) of each metal. To achieve Aim 2, researchers will use cell culture-based assays to determine how vaping aerosols, e-fluids, and metal constituents identified in Aim 1 affect gene and protein expression patterns and cellular function. They will also use wild-type and HDAC9-deficient mice to study the effects of chronic (1 month) vaping aerosol exposure on cardiovascular function (echocardiography), blood pressure, endothelial function, vascular reactivity, pulmonary function, and inflammation profile. Study findings may inform regulatory activities related to e-cigarettes.

A Mouse Model of Vaping Vitamin E Acetate: Effects on Lung Function and Pathology

In this CTP supplement to a parent grant (Effects of E-cigarette Exposure during Pregnancy on Offspring Lung Function and Disease: Characterization of Pulmonary, Intergenerational, and Epigenetic Effects), researchers will study the effects of inhaling vitamin E acetate (VEA) compared to aerosolized nicotine in propylene glycol/vegetable glycerol (PG/VG), which is linked to e-cigarette/vaping-associated lung injury (EVALI), on lung function and pathology in a mouse model. Study aims are: (1) to characterize the acute effects of vaping with increasing e-liquid percentage of VEA; and (2) to characterize the chronic effects of vaping VEA on lung function and pathology. To achieve Aim 1, researchers will expose mice that have not previously been exposed to vaping (naïve mice) and mice that have been exposed to house dust mite antigen (sensitized mice) or to aerosolized nicotine in PG/VG to increasing percentages (0, 10, 20, 40, or 80%) of VEA in PG/VG (1:1) e-liquid; researchers will determine VEA effects on pulse oximetry, bronchial lavage composition, and lung pathology compared to nicotine. At the optimal condition found to induce EVALI-like changes, researchers will determine the effects of modifying voltage. To achieve Aim 2, researchers will determine the chronic pulmonary effects of vaping (measured at 2 and 4 weeks) using a complete battery of pulmonary function tests, pulse oximetry, heart rate, bronchial lavage and lung pathology on naïve and sensitized mice. Study findings may inform the understanding of the link of pre-disposing factors, such as prior ENDS use, and pre-existing respiratory conditions, such as asthma, on the incidence of EVALI.

Impact of E-cigarette Prevention Messages on Adolescents

Additional research to inform effective communications related to e-cigarette prevention among adolescents would be useful. The goal of this project is to identify e-cigarette prevention messages that will reduce adolescents’ (ages 13-17) willingness to use e-cigarettes. Study aims are: (1) to identify promising ways to communicate with adolescents to prevent e-cigarette use; (2) to develop a set of e-cigarette prevention messages that discourage adolescents from wanting to use e-cigarettes; and (3) to evaluate whether prevention messages reduce at-risk adolescents’ willingness to use e-cigarettes and e-cigarette use behavior in a randomized controlled trial (RCT). To achieve Aim 1, researchers will: identify promising prevention message themes (e.g., health effects, social norms, addiction) targeted to adolescents based on the empirical literature; vet these themes with the study team, expert consultants, and a teen advisory panel; work with an advertising agency to develop creative concepts for the most prominent themes; and conduct six focus groups with about 60 adolescents to examine their responses to the creative concepts. To achieve Aim 2, researchers will: develop 10 e-cigarette prevention messages based on the chosen concepts from Aim 1; conduct 30 cognitive interviews with 10 tobacco-using, 10 tobacco-susceptible, and 10 non-susceptible non-user adolescents to refine the messages; and conduct an online study of 1,600 adolescents to examine the perceived effectiveness of the messages in discouraging e-cigarette use. To achieve Aim 3, researchers will select a set of the most promising messages from Aim 2 to test in an RCT with 506 adolescents who will receive daily text messages for 20 days; one group will receive one of the five e-cigarette prevention messages in a randomized order, while the other group will receive a control message such as “This study will help others in the future. Thanks for taking part!”. Researchers will examine the impact of messages on willingness to use e-cigarettes (primary outcome) and e-cigarette use, cognitive elaboration, negative affect, e-cigarette beliefs, and social interactions (secondary outcomes) with a brief daily assessment, 3 weekly surveys, and a survey at 3 months. Study findings may inform e-cigarette prevention messages and campaigns for adolescents.

Translational Studies on Electronic Cigarette-Derived Oxidants and Their Long-term Pulmonary Effects

Oxidative stress and damage resulting from exposure to oxidants such as free radicals and aldehydes play critical roles in the development and progression of most tobacco-caused diseases, including chronic obstructive pulmonary disease (COPD). The goal of this project is to evaluate toxicities caused by exposure to e-cigarette-derived free radicals and aldehydes and their role in the development of COPD. Study aims are: (1) to investigate the long-term pulmonary effects of e-cigarette exposure from products delivering high vs. low oxidant levels in a COPD mouse model; (2) to determine the impact of switching from cigarettes to e-cigarettes; and (3) to conduct a pilot single arm trial to determine the impact of switching from cigarettes to e-cigarettes on disease-related clinical symptoms and biomarkers of harm in smokers with preexisting COPD. To address Aim 1, researchers will conduct 3-month exposure studies to compare high vs. low oxidant e-cigarette products (Mod vs. Juul, respectively). To address Aim 2, researchers will pre-expose mice for 1.5 months to cigarette smoke prior to switching them to filtered air, e-cigarette aerosol, or 50/50 e-cigarette aerosol/cigarette smoke for the remaining 1.5 months to mimic the harm from “real world” e-cigarette use patterns in smokers (smoking cessation, switching to e-cigarettes, and dual use). The primary outcomes of Aims 1 and 2 will be development of a COPD phenotype (including changes in lung function and histology) and assessment of systemic and lung-specific biomarkers of oxidative stress/damage and inflammation. To address Aim 3, researchers will provide e-cigarettes to 30 smokers (ages 18-65) with mild/moderate COPD and ask them to use these products exclusively for a year; e-cigarette and cigarette usage will be monitored along with assessments of COPD-related clinical symptoms, spirometric lung function, and biomarkers of oxidative stress and inflammation. These studies will provide new information about the toxicological impact of oxidant exposure from specific e-cigarette devices.

Impact of Nicotine Messaging on Nicotine Beliefs and Tobacco Use Behavior

The public health impact of FDA’s proposed nicotine reduction policy hinges on the extent to which tobacco users and non-users understand the harms of nicotine in specific products (e.g., e-cigarettes, nicotine replacement therapy (NRT), reduced nicotine content (RNC) cigarettes) and how this understanding influences decisions made by non-users to try a product and by users regarding cessation, product switching, or continued use. Research has highlighted widespread public misperceptions of the health risks of nicotine. A brief nicotine corrective messaging intervention may correct misperceptions of nicotine, NRT, e-cigarettes, and RNC cigarettes. The goal of this study is to examine the effect of multiple exposures to a nicotine corrective messaging (NCM) intervention (compared to a delayed intervention control) on nicotine beliefs and intention/use of tobacco and nicotine products in U.S. adults (age 18 and older). Study aims are: (1) to test the impact of NCM on nicotine beliefs and the subsequent impact on intention and use of tobacco and nicotine products in a national sample of 715 adult smokers and non-smokers followed for 12 weeks; and (2) to test the impact of NCM (messaging vs. control) and nicotine content of study cigarettes (normal vs. reduced) on nicotine beliefs and subsequent use of tobacco and nicotine products using a 2 x 2 factorial design in a sample of 160 adult current smokers followed for 4 weeks (participants will be explicitly told which product they have been given). In both studies, participants will complete online surveys at scheduled intervals throughout the study period in which they will be exposed to up to six corrective messages and subsequently complete survey questions. Study findings will provide information about the potential of NCM communication efforts on tobacco use behavior in the general population and in adult smokers affected by a reduced nicotine content standard in combustible cigarettes.

Modified Use of E-Cigarettes and Marketing on YouTube

The goal of this study is to understand ways in which youth modify e-cigarettes, their motivations for doing so, and marketing sources. Study aims are: (1) to identify and characterize modified uses of e-cigarettes and associated marketing sources on youth-accessible YouTube videos, and (2) to examine modified uses and marketing exposure among an online sample of 500 adolescent (ages 13-17) and 500 young adult (ages 18-25) e-cigarette users. To address Aim 1, researchers will identify modified uses of e-cigarettes and marketing using fictitious youth YouTube viewer profiles to search for e-cigarettes using a browser plug-in and custom scripted web-crawling; then they will use machine-learning to automatically code the videos to identify e-cigarette modifications, motivations for modification, marketing sources, and appeal (number of views, number of likes). Subject matter experts in tobacco regulatory science, social media, youth tobacco use, toxicology, communications, and tobacco marketing will assess the potential impact of identified modified uses on e-cigarette appeal, addiction, and health effects. To address Aim 2, researchers will conduct an online survey with 1000 adolescent and young adult e-cigarette users to examine the prevalence, appeal, motivations, risk perceptions, and marketing exposure related to these modified uses and their predictors (i.e., demographic variables, past-month e-cigarette use frequency, e-cigarette dependence, other tobacco/substance use, interpersonal and intrapersonal risk factors). Findings may inform regulatory activities related to e-cigarettes.

Greenwashing Cigarettes: Perceptual and Behavioral Evidence of Inaccurate Modified Risk Advertising

“Greenwashing” is an increasingly common tobacco marketing strategy in which products are portrayed as eco-friendly and/or natural. Greenwashing tactics may inaccurately convey modified product risk to consumers. The goal of this project is to describe how cigarette companies use greenwashing to market their products and test the effect of these tactics on young adult (ages 18-29) risk perceptions in an online sample and actual smoking behavior in a controlled laboratory study. Study aims are: (1) to identify specific greenwashing tactics used in cigarette ads, determine their prevalence across brands and sub-brands, and determine changes in these tactics over time; (2) to test the extent to which the greenwashing tactics identified in Aim 1 contribute to inaccurate modified risk perception in 1,500 young adults using an online survey; and (3) to test the effect of greenwashing on behavioral economic demand and smoking topography in a laboratory-controlled cigarette self-administration study of 35 young adults. Findings will provide new information about the connection of greenwashing strategies to product risk perceptions and actual smoking behavior and may inform future regulatory activities.

Shrinking the Size of the Tobacco Powerwall and Restricting the Number of Tobacco Products Displayed to Reduce Adolescent Tobacco Use

The most prominent source of retail point-of-sale (POS) tobacco advertising comes from the tobacco power wall, the large, expansive display of hundreds of different tobacco products typically located behind the cashier in full view of consumers. Adolescents are frequent visitors to retail stores and thus are at significant risk for having repeated exposures to the tobacco power wall. The goal of this project is to experimentally evaluate the extent to which reducing the size of the tobacco power wall and the number of tobacco product units displayed influences tobacco use risk in adolescents. Study aims are: (1) to evaluate the extent to which reducing the size of the power wall and number of units of each tobacco product displayed on the power wall influences tobacco use risk; (2) to model the mediational pathways through which these reductions initiatives have their effects; and (3) to examine whether gender and/or tobacco use experience moderate adolescents’ reactions to the power wall regulatory options under investigation. This study will take place in the RAND StoreLab (RSL), a life-sized replica of a convenience store developed to evaluate how altering aspects of POS promotion influences tobacco use risk during simulated shopping experiences. A total of 750 adolescents (ages 11-20) will be randomly assigned to shop in the RSL under one of three conditions (250 per condition): (1) large power wall/ multiple product units displayed; (2) small power wall/multiple product units displayed; and (3) small power wall/single product units displayed. Researchers will consider the effect of these power wall alterations on risk of use of four classes of tobacco products: cigarettes, electronic nicotine delivery devices, cigarillos, and smokeless tobacco. Tobacco use risk will be indexed by: attention to the tobacco power wall, perceived tobacco use norms, perceived availability of tobacco products, and tobacco use intentions. Findings may inform future regulatory activities related to POS tobacco advertising.

Assessing Toxicant Properties and Health Effects of Cigarillo and Hookah Tobacco Aerosols in Rats

The goal of this project is to evaluate whether cigarillo and hookah tobacco aerosols exhibit differences in toxicants associated with five health outcomes (cancer, transcriptional reprogramming, lung function and inflammation, cardiovascular effects and serum circulatory inflammation) compared to cigarette smoke using a rat model. Study aims are: (1) to evaluate 14-day nose-only dose response exposures to aerosols generated from cigarettes, cigarillos, and hookah products; and (2) to evaluate the effect of these exposures on biomarkers of cardiopulmonary health effects. To address Aim 1, researchers will expose a total of 360 rats (10/sex/group) for one hour per day for 14 days to one of three exposure groups (250, 500, or 750 mg total particulate matter (TPM)/m3) and one of six tobacco products (two major consumer brands each of cigarettes, cigarillos, or hookah tobacco, selected based on their in vitro toxicant properties); an air exposure group of 20 rats will be included as a control group. The exposure atmosphere will be characterized for hazardous chemical substances including (but not limited to) carbon monoxide, tobacco-specific nitrosamines, nicotine, volatile carbonyls, and tar. To address Aim 2, researchers will use biospecimens collected following the exposures to assess and compare effects across the five health outcomes listed above. Researchers will obtain quantitative readouts of cardiopulmonary biomarkers to enable comparisons across products and to evaluate dose effects; biomarkers will include specific DNA adducts, lipid peroxidation, cytokine panels, global assessment of lung transcriptional reprogramming, gene expression changes in the heart and aorta, and gene expression changes predictive of circulatory inflammation. Findings may inform regulatory activities related to cigarillos and hookah tobacco.

Impact of Sugars on Tobacco Product Toxicity and Abuse Liability

Sugars are present naturally in some tobacco types and are also added to cigarette tobacco filler. Data suggest that sugars in tobacco filler may contribute to the harmful properties of cigarettes by enhancing smoke palatability and appeal and, as precursors to aldehydes and furans in smoke, by increasing smoke toxicity and carcinogenicity and potentially addictiveness. The goal of this study is to provide additional quantitative data on the relationship between tobacco sugar content and relevant toxicant yields in U.S. commercial cigarettes, and associated user exposures, behaviors, and cigarette appeal. Study aims are: (1) to characterize the impact of sugars in the filler of U.S. cigarettes on the chemical profile of cigarette smoke; (2) to investigate the impact of sugar content in cigarette tobacco on toxicant and carcinogen intake in U.S. smokers; and (3) to investigate the impact of sugar content in cigarette tobacco on cigarette abuse liability and appeal. To address Aim 1, researchers will add stable isotope-labeled sugars to a commercial cigarette that is low in sugars and will analyze the dose-dependent formation of corresponding pyrolysis products in the smoke of this cigarette; they will also analyze the impact of sugar content on the levels of nicotine and tobacco-specific nitrosamines (TSNAs) in the smoke. To address Aim 2, researchers will analyze sugars in U.S. commercial cigarettes and use Population Assessment of Tobacco and Heath (PATH) Study biomarker data to investigate the impact of sugar content in cigarette tobacco on toxicant and carcinogen intake in U.S. smokers. To address Aim 3, researchers will investigate the impact of sugar content on cigarette abuse liability and appeal by conducting a laboratory study in which 30 smokers (aged 18 and older) will assess study cigarettes with different sugar levels. Findings may inform future regulatory measures related to sugar levels in tobacco products.

Impact of a Reduced Nicotine Standard on Young Adult Appeal for Menthol and Non-Menthol Cigarettes

The goal of this study is to examine response to smoking menthol and non-menthol very low nicotine cigarettes (VLNCs) in 100 young adult (ages 18-24) menthol smokers. Study aims are: (1) to determine the influence of menthol flavoring on smoking reinforcement in the context of a reduced nicotine standard in the laboratory; (2) to determine the influence of menthol flavoring on smoking reinforcement in the context of a reduced nicotine standard in the natural environment; and (3) to examine the impact reinforcement on tobacco product purchasing. To achieve Aim 1, abstinent smokers (>12 hours) will attend three laboratory visits where they will smoke a cigarette. During Visit 1, smokers will smoke their usual brand cigarette ad libitum; researchers will measure subjective response (satisfaction, craving reduction, psychological reward, sensory effects like throat hit), smoking exposure (carbon monoxide [CO] boost), and behavior (number of puffs, puff volume). Next, after 7 days of usual brand smoking, participants will undergo two experimental conditions at home: (1) 7 days smoking menthol VLNCs; and (2) 7 days smoking non-menthol VLNCs. For each condition, participants will be instructed to switch their usual cigarette for the assigned research cigarette but may use other tobacco products. (Each experimental condition will be separated by a 7-day wash-out period.) On the last day of each condition, participants will smoke the assigned research cigarette in the laboratory, and researchers will collect data on subjective response, smoking exposure, and behavior to compare craving reduction, positive subjective response, and CO boost among menthol VLNCs, non-menthol VLNCs, and usual brand. To address Aim 2, during each 7-day period, participants will complete twice-daily assessments of cigarette and other tobacco use, withdrawal, and subjective response; data will allow researchers to compare cigarettes per day, craving reduction, and positive subjective response for menthol VLNCs, non-menthol VLNCs, and usual brand. To address Aim 3, in a fourth visit participants will complete two tasks in the laboratory to indicate the impact of menthol and nicotine content on cigarette purchasing behavior in the context of all tobacco products currently on the market. Findings will provide new information about the abuse liability of menthol VLNCs.

A Measurement Burst Study of Vaping in a National Sample of Young Adults

In this supplement to the Monitoring the Future (MTF) parent grant (Monitoring the Future: Drug Use and Lifestyles of American Youth), researchers will conduct a new longitudinal study of approximately 1100 individuals who participated in MTF as 12th graders in 2019 and will be modal age 19 in 2020, with an oversample of those who reported vaping and other substance use in high school. Approximately 570 respondents who report current vaping at age 19 will be invited to complete a one-time web-based survey (30 minutes) followed by 14 consecutive daily web-based surveys (5-7 minutes) to capture real-time fluctuation in vaping use patterns, consequences, and co-use with other substances. Study aims are to examine: (1) vaping frequency, products, devices, patterns, and contexts with daily data over two weeks, (2) signs of vaping addiction, craving, quit attempts, and physical consequences in real time, (3) co-use of vaping and other substances including alcohol, cigarettes, marijuana, and non-prescription drugs, and (4) recent exposure to nicotine through collection of biometric samples. Findings will provide new information about vaping behaviors and consequences among young adults that may inform future regulatory activities.

Identification of Free Radical Induced Biomarkers of Exposure to Electronic Cigarette Aerosol

E-cigarette aerosol contains highly reactive free radicals that can cause oxidative damage, which can contribute to the progression of cancers and other diseases. The goal of this study is to identify these free radicals and use their unique structures to develop an e-cigarette-specific biomarker of exposure. Study aims are: (1) to determine the structures of the free radicals produced by propylene glycol and glycerin in e-cigarettes; and (2) to determine the primary targets of radical adduct formation in the tissue of e-cigarette-exposed mice and identify metabolites formed from radical adducts in the serum. To address Aim 1, researchers will use free radical spin trapping, electron paramagnetic resonance spectroscopy techniques, and mass spectroscopy to identify and analyze the unique structural features of free radicals in e-cigarette aerosol produced from a popular temperature-controlled e-cigarette device. To address Aim 2, 120 mice will be exposed to e-cigarette aerosols and either pre- or post-exposed to 5,5-dimethyl-1-pyrroline noxide (DMPO) spin traps via nose-only exposures. Using an anti-DMPO antibody, the areas of free radical exposure will be observed in the pre-DMPO exposures and targets of radical damage will be observed in the post-DMPO exposures. Radical adducts formed in the post-DMPO exposures will be identified via mass spectroscopy and metabolites of these adducts will be identified in the serum to find viable e-cigarette-specific biomarkers of exposure. Findings may inform future regulatory activities related to e-cigarettes.

Cardiopulmonary Effects Induced by Electronic Cigarette and JUUL Aerosols in Both In Vivo and In Vitro Models

Although clinical evidence demonstrates declines in lung function and increases in heart attack risk in healthy dual-users of e-cigarettes and cigarettes, more evidence regarding the cardiopulmonary effects of chronic inhalation of electronic nicotine delivery system (ENDS) aerosols would be useful. The goal of this study is to evaluate how two ENDS products — open system e-cigarette devices and closed system JUUL-type devices — impact individual or combinations of aerosol constituents and their toxicity using innovative cell culture systems and mouse models. Study aims are: (1) to examine the roles that e-liquid constituents (i.e., propylene glycol/vegetable glycerin, flavors, nicotine) play in the chemical profiles and lung toxicity of ENDS aerosols using in vitro models; (2) to define a panel of biomarkers for cardiopulmonary effects following exposures to e-cigarette aerosols, JUUL aerosols, and dual use of cigarettes and e-cigarettes in juvenile mice; and (3) to compare pulmonary toxicity induced by e-cigarette or JUUL aerosols in mice. Findings may clarify the cardiopulmonary effects caused by prolonged use of ENDS and inform regulatory activities.

Yale Center for the Study of Tobacco Product Use and Addiction: Flavors, Nicotine and Other Constituents (YCSTP) (TCORS 2.0)

Systematic data collection can provide more information about e-cigarette or vaping product use-associated lung injury (EVALI), particularly regarding number of cases and specific products involved. In this supplement to the Yale University TCORS 2.0 parent grant, researchers will develop a robust surveillance system that will prospectively identify hospitalized patients with acute lung injury who vape or smoke. Study aims are: (1) to develop a robust surveillance system to prospectively identify admitted patients with acute lung injury who vape or smoke; (2) to perform toxicology analyses of e-liquids and device contents that are associated with EVALI; and (3) to build a biorepository of patient blood and urine samples among patients with acute lung injury who vape or smoke to investigate disease mechanisms. This project will enable research into disease mechanisms and elucidate risk factors associated with EVALI.

Center for the Study of Tobacco Products – Electronic Cigarette Use and Alveolar Macrophages: A Preliminary Study

Data from animal studies suggest that e-cigarette users may be at risk for a potentially debilitating condition called lipoid pneumonia. In this supplement to the Virginia Commonwealth University TCORS 2.0 parent grant, this supplement will collect pilot data relevant to the generalizability of lipoid pneumonia-related animal study data to humans. Study aims are: (1) to investigate lipid-laden macrophages in e-cigarette users, and (2) to characterize other disease biomarkers in e-cigarette users’ bronchoalveolar lavage (BAL) fluid. To address Aim 1, researchers will recruit 10 high-wattage (i.e., >20 W) e-cigarette users (ages 21-55) with over one year of experience exclusively using nicotine-containing e-cigarettes as well as an additional 10 never-e-cigarette-using, never-smoking controls. Using well-established methods, all 20 participants will undergo bronchoscopy and BAL to enable the collection of alveolar macrophages. Researchers will then compare the incidence of lipid-laden macrophages between groups. To satisfy Aim 2, researchers will determine the alveolar fluid composition differences in miRNA expression, extra-vesicle-miRNA, and microbiome profiles between the e-cigarette users and the control group. Findings may inform regulatory activities related to e-cigarette liquid constituents that have the potential to cause lung disease.

FDA CTP This is Our Watch Retailer Feedback Study

FDA’s Center for Tobacco Products (CTP) Office of Health Communication and Education has created and maintains retailer education materials, referred to as This Is Our Watch (TIOW), designed to give retailers the tools they need to comply with tobacco regulations. As a result of the Tobacco 21 legislation raising the federal minimum age for the sale of tobacco products from 18 to 21, FDA CTP is required to update TIOW retailer education materials. The goal of this study is to obtain feedback from retailers about their awareness, preferences and experiences related to the TIOW materials. Researchers will conduct 32 in-depth interviews (22 English, 10 Spanish) that will each last up to 60 minutes. Participants will include clerks, managers, and owners of tobacco retail establishments identified through government contacts, such as the State Synar Program managed by the Substance Abuse and Mental Health Services Administration (SAMHSA). Study aims are: (1) to identify T21 knowledge gaps and educational opportunities among tobacco retailers, and (2) to understand retailers’ sentiments, needs and challenges related to minimum legal purchase age compliance. Findings will allow FDA to understand what additional messages, information, and material format would complement the current TIOW education materials.

The Human Dose-Response Effects of Methyl Salicylate in Smokeless Tobacco

The goals of this project are to determine how changes in the methyl salicylate content of smokeless tobacco may affect HPHC exposure and nicotine pharmacokinetics (the body’s effects on nicotine), as well as to determine how changes in methyl salicylate content affect nicotine pharmacodynamics (nicotine’s effects on the body) and abuse liability. First, researchers will amend commercially available smokeless tobacco to create four investigational smokeless tobacco products (no methyl salicylate and low, medium, and high methyl salicylate content ranging from 0.3-30 mg/g). Next, researchers will administer each of the four products to 56 adult smokeless tobacco users (aged 21-65) under specific use conditions. Researchers will measure heart rate, blood pressure, pharmacokinetics, exposure to harmful and potentially harmfully constituents (HPHCs), and abuse liability (measures of liking, craving, and withdrawal) before and after product use. Findings may inform future regulatory activities related to smokeless tobacco products.

Study of E-Cigarette Aerosol Toxicity in In Vivo Nonclinical Models

Few peer-reviewed studies have compared the toxicity associated with inhaling aerosol from different types of e-cigarettes; therefore, a thorough comparison of the chemical constituent levels, pharmacokinetics (PK), and toxicity from different e-cigarettes would be informative for future toxicological assessments. Researchers will perform a 28-day study with PK assessment, a 90-day nose-only inhalation study with 45-day recovery groups, and a 6-month nose-only inhalation study; all studies will be conducted in male and female Sprague Dawley rats. The 28-day study will evaluate the toxicity of two e-cigarettes and will provide PK data (results will be used to inform dose selection in the 90-day and 6-month studies). The objective of the 90-day and 6-month studies is to perform longer-term comprehensive studies of four top-market-share e-cigarette products in the U.S. Researchers will gather data including e-liquid and aerosol concentration measurements; measurements in animals such as body weight and food/water consumption; clinical observations; and biomarkers of exposure. Findings will provide new information about the potential toxicological effects of e-cigarette use.

Smokers’ Decision-Making about Tobacco Use: The Interplay of Affective and Cognitive Factors with Product Characteristics

Misperceptions about the health risks and benefits of electronic nicotine delivery systems (ENDS) and heated tobacco products (HTP), as well as consumer dissatisfaction with product characteristics, may limit initiation and complete substitution for cigarettes. This project will investigate how price, indoor-air policies, and ENDS and HTP product characteristics (type/design, flavors, ability to reduce cravings to smoke) interact with risk/benefit perceptions to affect smokers’ decisions to reject ENDS, to substitute them for only a few cigarettes, to switch exclusively to ENDS, or to use ENDS to completely quit using tobacco products. Study aims are: (1) to examine how cognitive, affective, and contextual factors (e.g., whether products can be used where smoking is prohibited) moderate the influence of ENDS/HTP product characteristics on product choice and tobacco use patterns and trajectories; and (2) to examine how the effects of specific ENDS/HTP product characteristics on product use patterns are moderated by risk/benefit perceptions. Aim 1 will involve qualitative focus group interviews with 120 current and former adult smokers (aged 18+) and an intensive one-year (12 weekly, then 3 quarterly) assessment with 300 current smokers who recently initiated ENDS use to examine how ENDS/HTP product characteristics influence smokers’ decisions to initiate, dual use with, or substitute for combustible product use. Aim 2 involves two experiments and a randomized clinical trial. A discrete-choice experiment (DCE) will be embedded in a survey of 300 current adult smokers to examine the relative importance of ENDS/HTP product characteristics on risk/benefit perceptions, product preferences, and use intentions, and evaluate the predictive validity of these preferences on future tobacco use. A second DCE will examine the interaction of product characteristics, risk/benefit perceptions, and contextual factors on product preferences among 2,400 adult current smokers who currently, formerly, or never used ENDS/HTP products. These results will inform the design of a randomized clinical trial with 1,800 adult smokers involving a hypothetical purchase task that will manipulate risk/benefit perceptions of ENDS/HTP products to estimate the effect on smokers’ consumption of cigarettes, ENDS, and HTP, including the substitutability or complementarity of ENDS and HTP for each other and for cigarettes. Findings may inform regulatory activities related to cigarettes, ENDS and HTP products.

Assessing IQOS Marketing Influences and Consumer Behavior in Israel: Implications for the US

Developing an understanding of how heated tobacco products (HTPs) are marketed would be useful. IQOS, the global HTP leader, has a presence in several markets, including Israel. Israel is unique in that it represents three distinct regulatory contexts for IQOS: (1) during IQOS’s initial emergence in Israel, it was not categorized as a tobacco product (Dec 2016-Apr 2017); (2) IQOS was classified as a tobacco product in a relatively weak regulatory context (Apr 2017- December 2019); and (3) IQOS will be regulated as a tobacco product within new progressive legislation (study period starting January 2020). The goal of this study is to examine IQOS marketing strategies used in Israel during these three regulatory periods and assess their impact on segments of the Israeli and U.S. populations. Study aims are: (1) to examine IQOS marketing strategies in Israel from its emergence in the Israeli market and begin surveillance as IQOS is launched in the US; and (2) to examine market segments of Israeli and U.S. adults (users and nonusers aged 18-45) in relation to IQOS use and/or likelihood of future use. The researchers will study marketing content and consumer reactions in both Israel and the U.S. via examination of marketing channels (including point-of-sale audits), content analysis of advertising messaging strategies, interviews with IQOS retailers, online surveys of 1,000 Israeli and 1,000 U.S. adults, and interviews with 40 Israeli and 40 U.S. adults. Among the panel of Israeli and U.S. adults, the researchers will conduct market segmentation research on consumer characteristics; four specific market segments defined by the IQOS website will be examined: business and current events; art, culture and fashion; nature and hiking; and innovation and technology. By examining IQOS marketing strategies used in the three different regulatory periods in Israel and understanding the impact of these strategies on different consumer segments and the extent to which they generalize to U.S. consumers, findings will provide information to better estimate the potential impact of IQOS and its marketing in the U.S.

Assessing the Effects of Smokeless Tobacco Influencer Marketing in the Rapidly Changing Media Environment

Social media marketing remains an understudied area in tobacco control, particularly related to smokeless tobacco. The goal of this project is to examine the effects of exposure to smokeless tobacco-related social media content. Study aims are: (1) to conduct a content analysis to identify and characterize social media messages related to smokeless tobacco by source and major themes (e.g., new user targeting, health risks, flavors); (2) to assess the impact of social media content exposure on smokeless tobacco use, attitudes, harm perceptions, perceived prevalence of use, initiation, and use intentions) using data from the Truth Longitudinal Cohort Survey on Tobacco-Related Attitudes, Beliefs and Behavior (13,892 youth and young adults aged 15-21 at baseline [April 2014]); and (3) to study whether/to what extent tobacco control policies moderate the relationship between exposure to smokeless tobacco-related social media content and smokeless tobacco use. Investigators will apply various research and analytic methods to a unique combination of data sets, including social media data from Twitter, Instagram and Facebook and survey data on tobacco-related outcomes. Findings will provide policy-relevant scientific evidence on the impact of social media marketing of smokeless tobacco products.

The E-Cigarette Population Paradox: Testing Effects of Youth-Targeted Population Warnings for E-Cigarettes among Two Key Populations

Warnings on e-cigarette advertisements and packaging should communicate the risks of e-cigarettes to youth and non-smokers while also protecting perceptions of the potential benefits of switching completely to e-cigarettes among combustible cigarette smokers. The goal of this study is to identify effective e-cigarette ad warnings given this complex population paradox. Study aims are: (1) to develop and test a set of proposed warning messages to maximize desirable outcomes among both nonsmoking youth and adult smokers; (2) to evaluate e-cigarette ad warnings that maximize favorable effects on youth as the critical at-risk population; and (3) to test for unintended effects of e-cigarette ad warnings among adult cigarette smokers who may be discouraged from switching to e-cigarettes when exposed to some types of warnings. To address Aim 1, researchers will conduct a series of 16 focus groups (30 youth aged 14-18 and 30 adults aged 19+) to identify warnings that are likely to discourage non-smoking youth from using the product but do not discourage cigarette smokers from wanting to switch completely. To address Aim 2, researchers will use a mobile lab outfitted with computing and eye-tracking technology to test the effects of promising warnings from Aim 1 in a randomized experiment with 400 youth aged 14-18 to identify warnings that increase visual attention to the warnings, decrease attention to ad appeals, increase risk beliefs, and reduce use intentions. To address Aim 3, using the same mobile lab, researchers will randomize 400 adults aged 19+ to test whether the most effective warnings among youth that emerge in Aim 2 have any unintended consequences among adult smokers; specifically, they will test whether youth-effective warnings influence visual attention, comparative risks between combustible and e-cigarettes, and intentions to use both products (switching completely to e-cigarettes, dual use, or continued smoking of combustible cigarettes) among adults. Findings may inform regulatory activities related to e-cigarette ad warnings.

Advancing Perceived Message Effectiveness: A New Measure for Youth Prevention Media Campaigns

Among other tools, the FDA uses the perceived message effectiveness (PME) scale to select ads for The Real Cost campaign. However, this scale has some limitations, including: (1) it was developed with adult smokers; (2) it was developed before the advent of e-cigarettes and vaping; and (3) it assesses message PME (beliefs about the message; i.e., “This ad is informative”), while a growing body of literature suggests that effects PME (beliefs about the message’s impact; i.e., “This ad gives me good reasons not to smoke”) better predicts the impact of ads on intention and behavior change. The goals of this project are to develop and validate an effects PME scale for adolescent (aged 13-17) tobacco prevention and to compare the performance of this new scale to the FDA’s current message PME scale. Study aims are: (1) to develop a youth effects PME scale for vetting cigarette and e-cigarette prevention ads; (2) to establish whether effects and message PME prospectively predict the impact of smoking prevention ads on intentions to smoke cigarettes; and (3) to examine whether effects and message PME predict the impact of vaping prevention ads on intentions to vape. To achieve Aim 1, researchers will develop a youth effects PME scale for vetting cigarette and e-cigarette prevention ads. They will develop and refine an item pool, cognitively test items with 48 adolescents, and conduct a scale development study with a national sample of 800 adolescents. To achieve Aim 2, researchers will randomize 1,280 adolescents at risk of cigarette smoking to one of three The Real Cost cigarette prevention ad conditions or to a control ad condition; participants will view a set of ads each week and complete a final assessment at week 3, and the researchers will examine whether PME predicts the impact of ads on intentions to smoke, risk beliefs about smoking, and smoking behavior. To achieve Aim 3, researchers will randomize 1,024 adolescents to view three The Real Cost e-cigarette ads or to a control ad condition and examine whether PME predicts the impact of e-cigarette ads on intentions to vape and risk beliefs. Findings may help campaign designers select more effective ads, thereby increasing the impact of tobacco education campaigns targeted to youth.

Communicating about Nicotine and Differential Risks of Tobacco Products

The goal of this project is to study a communication strategy that combines messages about reduced nicotine in combusted cigarettes with messages about relative risks of other tobacco products (i.e., potential “modified risk claims”). Study aims are: (1) to develop preliminary messages about reduced nicotine in combusted tobacco products; (2) to quantify the relative importance of different types of information in communications about reduced nicotine; and (3) to test the impact of messages about reduced nicotine in combusted tobacco products in the context of potential modified risk statements for novel tobacco products in a randomized clinical trial. To achieve Aim 1, researchers will conduct focus groups with 36 adult (aged 18+) current exclusive smokers, 36 adult dual users of cigarettes and ENDS, 36 adult former smokers, and 36 young adult non-smokers (aged 18-29). To achieve Aim 2, researchers will assess the relative effects of various message attributes (e.g., specific numbers for reduction, mention of addiction and health effects, source) on affect, perceived risk, and intentions to quit (for smokers) or to try reduced nicotine cigarettes (for non-smokers) in a discrete choice experiment; participants will be adult current exclusive smokers, adult dual users, adult former smokers, and young adult non-smokers (450 from each group). To achieve Aim 3, researchers will conduct a randomized clinical trial with 900 adult current exclusive smokers, 450 adult dual users, and 450 young adult non-smokers to compare effects of reduced nicotine and potential modified risk messages (executed as full-color ads) alone and in combination; outcomes will include risk perceptions, affect, behavioral intentions and recall and behavioral outcomes. Findings may inform regulatory activities related to communication strategies involving low nicotine tobacco products.

Impact of Adding Tobacco Constituents Nornicotine and Anatabine on Self-Administered Nicotine

Because most electronic cigarettes contain nicotine, users may be at greater risk of transitioning to other tobacco products given the addictive nature of nicotine. More information about the interactions between nicotine and other tobacco constituent compounds in the context of this addictive risk would be useful. The objective of this research is to assess the impact of the addition of other tobacco constituent compounds to nicotine in an intravenous self-administration model in male and female adult and adolescent rats. Study aims are: (1) to assess the impact of adding nornicotine and anatabine to self-administered nicotine on the motivational value of nicotine in rats that began their nicotine consumption as adults; and (2) to assess the impact of adding those constituents to self-administered nicotine on the motivational value of nicotine in rats that began their nicotine consumption as adolescents. Findings on the impact of adding tobacco constituent compounds to ongoing nicotine self-administration may inform future regulatory activities.

The Role of Humectants and Flavor on Microbial Growth in Waterpipe Tobacco

More information regarding how additives like humectants and flavors alter microorganisms in waterpipe tobacco would be useful. The goal of this study is to assess the impact of humectants (humidifying ingredients) and flavor additives on microbial growth in waterpipe tobacco. Study aims are: (1) to evaluate the effect of flavor and humectant content on microbial growth in waterpipe tobacco; and (2) to assess the relationship between tobacco-specific nitrosamine (TSNA) production and microbial activity in waterpipe tobacco. To address Aim 1, researchers will use an unflavored, low-humectant commercially available waterpipe tobacco as a control and prepare it several different ways to determine the individual and cumulative effects of additives (glycerin, propylene glycol, and vanillin) on microbial growth; flavor and humectants will be added at quantities comparable to those in commercially available waterpipe tobacco. Researchers will quantify microbial composition using whole genome sequencing analysis, and will use shotgun proteomic analysis to characterize proteins expressed by organisms colonizing tobacco. To achieve Aim 2, two TSNAs (Nʹ-nitrosonornicotine [NNN] and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone [NNK]) will be quantified in each tobacco preparation after 1 and 6 months of incubation and compared to levels found in the control. Study findings will provide new information about how humectants and flavors influence toxic exposures associated with waterpipe tobacco.

E-Cigarettes and Youth: Tests of Strategies to Prevent Recreational Use

Use of e-cigarettes by non-smoking youth has increased dramatically in recent years. The goal of this study is to test how variations in modified risk statements, novelty flavors, and flavor representation (pictorial images vs. plain-text flavor names) influence middle school youth (aged 11-14) e-cigarette perceptions and use susceptibility. Study aims are: (1) to determine how modified risk statements and the specificity of the health risks addressed by them influence middle school students’ perceptions of e-cigarettes and the FDA’s warning label; (2) to determine how flavor category influences middle school students’ perceptions of e-cigarettes and the FDA’s warning label; and (3) to determine how flavor representation influences middle school students’ perceptions of e-cigarettes and the FDA’s warning label. Two randomized experiments will be conducted on a sample of middle school students. The first, with 150 participants, will vary whether participants view a modified risk statement alongside the FDA warning on e-cigarette packages, as well as the type of modified risk statement (abstract health consequence vs. specific health consequence). The second experiment, with 550 participants, will vary whether participants view e-liquid vials with tobacco flavor or a novelty flavor (menthol, fruit, candy, goth). Outcome measures include risk perceptions, message comprehension, harm minimizing beliefs, susceptibility, and behavioral intentions toward e-cigarette uptake. Findings may inform communication strategies that minimize uptake of e-cigarettes by middle school youth.

Evaluating the Impact of Waterpipe Tobacco Marketing Claims on Young Adults

Specific evidence related to waterpipe tobacco packaging and marketing to identify claims and determine their influence on consumer harm misperceptions would be useful. The goal of this study is to document claims on waterpipe tobacco packaging and in digital marketing (websites and social media) and evaluate how such claims influence consumer perceptions and willingness to try waterpipe tobacco. Study aims are: (1) to identify waterpipe tobacco product packaging and digital marketing; (2) to analyze waterpipe tobacco product packaging and digital marketing to determine whether they contain health claims; and (3) to evaluate the impact of health claims on young adults’ willingness to try the product, product appeal, and perceptions of harm. To achieve Aim 1, researchers will we will select a random sample of 30 waterpipe tobacco manufacturers and purchase five flavors from each manufacturer to document claims made on product packaging (150 packages). Researchers will also randomly select 30 U.S. retailers (i.e., waterpipe cafés, bars, lounges). For each of the 30 manufacturers and 30 retailers identified, researchers will capture content from their websites, as well as capture the 20 most recent Instagram (n=1,200) and Facebook (n=1,200) posts. To achieve Aim 2, researchers will content analyze all the packaging and digital marketing content captured in Aim 1. They will then use an expert panel to determine whether claims found on packaging and in digital marketing are health claims. To achieve Aim 3, researchers will conduct a randomized online experiment with 1,500 young adults (aged 18-29), including waterpipe users or those susceptible to future use, to evaluate the impact of the health claims on willingness to try the product, perceptions of harm, and product appeal. Findings will provide new information about which claims consumers perceive as health claims and may inform related regulatory activities.

Analysis of ENDS Products

The goal of this project is to identify which of the 93 harmful and potentially harmful constituents (HPHCs) identified by the FDA are present in electronic nicotine delivery system (ENDS) products. Using validated testing methods, researchers will analyze ENDS e-liquids (33 e-liquids and four disposable devices containing e-liquid cartridges) and ENDS aerosols (aerosols of the 33 e-liquids produced from 21 different ENDS devices). In addition, researchers will provide relevant information (when available) about the products’ physical attributes and design characteristics, including e-liquid volume or weight, labelled nicotine concentration, power output, resistance, heating coil temperature, and battery capacity.

CTP Supplement to Parent Grant: Center for the Assessment of the Public Health Impact of Tobacco Regulations – Diversity Supplement for Project 3 (TCORS 2.0)

This is a supplement to an existing study titled “Modeling the Impact of Tobacco Control Policies on Polytobacco Use and Associated Health Disparities.” The aims of the supplemental research study are: (1) to evaluate the relationship between perceived discrimination and individual tobacco product use by race/ethnicity and gender; and (2) to evaluate the relationship between perceived discrimination and polytobacco use by race/ethnicity and gender. Using nationally representative data of adults aged 18 years and older, the study will examine the role of perceived discrimination on the use of cigarettes, cigars, pipe, smokeless tobacco, and e-cigarettes, individually and in combination. Importantly, differences by race/ethnicity (i.e., non-Hispanic White, non-Hispanic Black, Hispanic, and other races) and gender will be examined. Findings may lead to a better understanding of the complex interplay between social determinants and tobacco-related health disparities of polytobacco use among racial/ethnic minorities.

Modeling the Public Health Impact of a National Menthol Cigarette Ban

The goal of this project is to use microsimulation modeling to estimate the impact of a national menthol cigarette ban on tobacco use and tobacco-related disease, specifically cardiovascular disease (CVD) and tobacco-related cancers. Study aims are: (1) to identify trajectories of cigarette use over time among youth and adults using longitudinal, nationally representative survey data; (2) to conduct a review of studies examining the effects of a menthol cigarette ban on product use; and (3) to build a model of smoking and tobacco-related disease to estimate the impact of a national menthol cigarette ban on smoking, CVD, and tobacco-related cancers. To achieve Aim 1, the researcher will compute transition probabilities of tobacco use behavior (frequency, intensity, flavor preference) over time using Population Assessment on Tobacco and Health (PATH) Study data. To achieve Aim 2, the researcher will synthesize the literature on the impact of a menthol cigarette ban and conduct a meta-analysis to pool data from individual studies, generating critical information for simulation modeling. To achieve Aim 3, the researcher will build a microsimulation model of tobacco use and tobacco-related diseases, incorporate the effect of a national menthol cigarette ban on cigarette use, and estimate changes in smoking, CVD, and tobacco-related cancers that would occur in the total population and in specific socioeconomic and racial/ethnic groups if a ban were implemented. Findings may inform potential regulatory activities on menthol cigarettes.

Prospective Health Outcomes and Inflammatory Biomarkers Associated with e-Cigarette Use

The goal of this project is to identify validated biomarkers for use in the assessment of electronic nicotine delivery systems (ENDS). By analyzing data from two studies (the COPDGene and UCSD ENDS studies), researchers propose to identify ENDS-related inflammatory biomarkers in ENDS-only and dual (ENDS + cigarette) users and relate these biomarkers to five-year lung health outcomes. COPDGene is an ongoing longitudinal study of >6,000 current and former cigarette smokers; the study is identifying factors that increase chronic obstructive pulmonary disease (COPD) risk and includes detailed longitudinal lung phenotyping data (including chest computed tomography [CT]), genome-wide blood RNA-sequencing, and proteomic data. The UCSD ENDS Study is a study of young ENDS-only users and controls involving detailed assessment of inflammatory biomarkers in the oropharynx, airways and blood. Study aims are: (1) to identify and validate inflammatory transcriptomic and proteomic biomarkers of ENDS exposure in ENDS-only and dual users from the COPDGene five-year study visit; biomarkers will be validated in two independent sets of subjects from the COPDGene ten-year visit and the UCSD ENDS Study; (2) to identify antibody-specific adaptive immune response biomarkers of ENDS exposure in ENDS-only and dual users using adaptive immune receptor repertoire sequencing; and (3) to relate ENDS use and biomarker panels to five-year lung health outcomes using spirometry, chest CT, and questionnaire data from COPDGene. Findings may inform future regulatory activities related to ENDS.

Using PET to Measure Pulmonary Oxidative Stress in E-cigarette Users

Inducible nitric oxide synthase (iNOS) is an enzyme that is expressed in lung epithelium and causes inflammation, a common pathway for many types of lung disease. Researchers will measure lung inflammation using positron emission tomography (PET) imaging with [18F]-6-(1/2)(2-fluoro-propyl)-4-methylpyridin-2-amine ([18F]NOS), a new PET radiotracer that targets iNOS. The goal of the study is to use this technique to compare lung inflammation in adult (aged 18+) electronic nicotine delivery system (ENDS) users, cigarette smokers, and nonsmokers. Study aims are: (1) to quantify and localize the effects of ENDS use, cigarette smoking, and nonsmoking on lung inflammation, and (2) to examine the effect of ENDS use, cigarette smoking, and nonsmoking on biomarkers of airway and lung inflammation and lung function. To accomplish these aims, 60 subjects (three groups of 20: ENDS users, traditional cigarette smokers who report having smoked ≥10 cigarettes per day for the past year with no history of ENDS use or cannabis smoking, and nonsmoking controls) will complete self-report measures, undergo a one-hour [18F]NOS PET/CT (computed tomography) scan of the chest, provide a breath and blood sample for measurement of biomarkers of airway and lung inflammation, and complete lung function tests using spirometry. Researchers will compare biomarkers of airway (fractional exhaled nitric oxide (FeNO)) and lung inflammation (proinflammatory cytokines TNF-α, IL-1β, and IL-8) and lung function (forced expiratory volume (FEV), forced vital capacity (FVC)). Findings may inform regulatory activities related to ENDS.

The Impact of E-cigarette Marketing Features on Youths’ E-cigarette Perceptions and Use Intentions

The goal of this study is to determine the impact of branded e-cigarette marketing features – such as color, use of people in images, and language specifically targeting smokers – on e-cigarette perceptions and use intentions among youth. Study aims are: (1) to examine the e-cigarette marketing context surrounding youth over time; (2) to assess the impact of e-cigarette marketing features on youth’s e-cigarette perceptions and use intentions; and (3) to explore the impact of branded e-cigarette marketing features on youths’ attention using eye tracking. Studies will be conducted with non-current users of e-cigarettes who are aged 13-17. To achieve Aim 1, the researcher will conduct a longitudinal content analysis over five years, as well as yearly, of print, online, and point-of-sale marketing materials for five brands of e-cigarettes to monitor the potential for youth exposure and to identify e-cigarette marketing trends. To achieve Aim 2, the researcher will first conduct four online focus groups (each with 8-12 youth) to understand their perceptions about e-cigarettes and e-cigarette marketing; the researcher will then conduct an online survey experiment with 600 youth to test the effects of use of color, use of people in images, and language specifically targeting smokers on e-cigarette perceptions and use intentions. To achieve Aim 3, the researcher will use eye tracking technology to objectively measure attention (e.g., dwell time, gaze patterns) among 60 youth exposed to e-cigarette marketing materials. Findings may inform future regulatory activities related to e-cigarette marketing, packaging, and labeling.

CTP Supplement to Parent Grant: Graphic and Text-Based Waterpipe Warning Labels to Combat Harm Misperceptions

This study is a supplement to a parent study that investigated the impact of the placement of text-only or graphic-and-text health warning labels on waterpipes on smoking behavior and toxicant exposure. The supplemental study will investigate warning label placement and whether changes in participants’ waterpipe smoking behavior due to warning labels result in measurable changes in biomarkers of potential harm and puffing behavior. The parent study aims are: (1) to determine the optimal message and placement of the health warning label on a waterpipe to attract user attention; (2) determine the effect of the presence of the optimal text vs. text/graphic vs. no health warning label on a carbon monoxide biomarker, waterpipe puffing behavior, and other behaviors, including perceptions of risk as measured by the social interaction among participants during the waterpipe smoking session; and (3) to explore the impact of the presence of a health warning label (text vs. text/graphic) on smoking behavior at 3 and 6 months post-experiment. For Aim 1, researchers will determine the optimal placement of heath warning labels on different waterpipes using focus group methods (n = up to 36) and eye tracking research (n=72) in samples of young adults ages 18-29 years. For Aim 2, researchers will randomize 246 young adults (ages 21-29 years) to view text-only labels, text/graphic labels, or no health warning label on waterpipes that they smoke ad libitum in a controlled laboratory setting; outcomes will include waterpipe puffing topography measures; subjective ratings of nicotine dependence, craving, and liking/disliking; exhaled carbon monoxide; and conversation topics related to fear, health risks, and the health warning label. For Aim 3, researchers will measure changes in smoking behavior at 3 and 6 months after the experiment. The supplement will add spirometry and genotoxicity measures to the laboratory experiment and the 3-month assessment in order to study lung function and biomarkers of harm, respectively. This study will provide new information about waterpipe health warning labels that may inform regulatory activities.

A State-of-Art NMR Technique to Investigate Biologicals Effects of Electronic Nicotine Delivery Systems

More information regarding the molecular structures of electronic nicotine delivery system (ENDS) aerosols and their biological consequences would be useful. The goal of this study is to determine whether ENDS use at different temperatures alters aerosol constituents and/or molecular structure and toxicity by identifying and using metabolic signatures. Specific aims are: (1) to investigate the formation of ENDS aerosols at different temperatures using a magic angle spinning (MAS) technique, and (2) to apply a non-destructive slow-MAS nuclear magnetic resonance (NMR) metabolomics platform to define the dynamic response of lung organotypic cultures to ENDS aerosols. To address Aim 1, researchers will use their recently developed in situ MAS technique, which generates high resolution NMR spectra on samples containing a mixture of gases, liquids, and solids at significantly elevated temperature and pressure. To address Aim 2, researchers will use their lung organotypic culture platform, which enables the investigation of single cell populations (e.g., normal vs. cancer cells) as well as mixed cell populations (e.g., normal/cancer cell co-cultures) to define the baseline metabolome of normal human lung epithelial cells, lung cancer cells, and their mixture as cultures, as well as changes induced by ENDS aerosols generated at different temperatures. Findings may inform regulatory activities related to ENDS.

Early Phase Pharmacokinetic Analysis of Nicotine in Sprague-Dawley Rats

Nicotine is a naturally occurring alkaloid that is found in many nightshade plants, with most human exposure occurring through exposure to tobacco. The CTP-NCTR InhaleCore Group has recently completed studies evaluating nicotine pharmacokinetics (PK) profiles in rats following a single dose administration by inhalation, oral gavage, and intravenous injection (E07607.01). In these studies, the dose formulations for inhalation exposure consisted of nicotine in propylene glycol and water. PK samples were collected at 10 different timepoints ranging from 3 minutes to 48 hours post-dose exposure. Early PK timepoints (< 15 minutes post-dose) were collected using venous blood via the tail vein (i.e., peripheral source), whereas later PK timepoints were collected using arterial blood via terminal cardiac puncture (i.e., systemic source). For the venous blood to reflect the PK sample of the arterial blood, a minimum of 15 minutes is needed post-dose exposure. In this study, early PK timepoints will be collected using arterial blood via cardiac puncture to obtain a more accurate assessment of nicotine levels post-dose exposure. Two timepoints (5 and 10 minutes) to replace the timepoints from the previous study data collection via the tail vein and one additional 30-minute timepoint will be included, to provide an overlapping datapoint with the previous study data collection via cardiac puncture. Results will provide useful information to characterize nicotine kinetics across different routes of exposure, which is critical for the development of the physiologically-based PK model for nicotine and its metabolites (cotinine and 3-hydroxycotinine) in rodents across different routes of exposure. This scientific data may be used to identify and assess potential public health concerns related to nicotine inhalation exposure and may inform potential nicotine product standards.

Little Cigar and Cigarillo Warnings to Reduce Tobacco-Related Cancers and Disease

Few studies have examined the effectiveness of currently mandated little cigar and cigarillo (LCC) warnings. The goal of this study is to clarify which LCC warning characteristics (i.e., content, format, size) are most influential in reducing LCC use and how an additional LCC policy, the removal of flavor descriptors on packaging, could influence LCC warning impact. Study aims are: (1) to develop a comprehensive set of effective LCC warning statements and images; (2) to determine whether effective LCC warnings increase LCC quit intentions; and (3) to determine how removal of LCC flavor descriptors on packaging further impacts attention and affective responses to LCC warnings. To address Aim 1, researchers will use existing research and expert review to develop new LCC warnings (text plus images) and test them using online experiments with 500 adult (aged 18-65) LCC users to identify warnings that subjects perceive to be the most effective. To address Aim 2, researchers will conduct a national, web-based randomized controlled trial with 900 adult LCC users to examine whether the most effective warnings identified in Aim 1 encourage quitting compared to the currently mandated warnings and a control condition. To address Aim 3, researchers will conduct an in-person laboratory study with 100 adult LCC users using objective measures of attention (eye tracking), affect (facial electromyography), and arousal (electrodermal activity) to determine how flavor descriptors influence the effectiveness of new warnings compared to currently mandated warnings. Findings may inform regulatory activities related to LCC warnings.

Using Social Media for Tobacco Regulatory Intelligence

This research involves two projects that will use artificial intelligence (Al) methods to analyze social media posts and comments. Researchers will apply Al models to messages collected from Twitter and Reddit; these models will enable the timely identification, organization, and analysis of millions of social media posts and comments. Separate models will be developed for Twitter and Reddit, which will allow researchers to compare and contrast findings from the two social media platforms. Project 1 will detect and identify tobacco brands and products from a list of previously established brands and products. Project 2 will identify the mentions of tobacco product-related adverse events (e.g., burns from e-cigarettes, vaping lung illnesses) and the perceived health benefits and harms of tobacco products. Project findings will provide new information that may inform FDA regulatory activities and communications.

Understanding How Flavors and Nicotine are Used in Electronic Nicotine Delivery Systems Advertising (Phase 2)

This work represents an extension of earlier CERSI-funded analysis of the content of electronic nicotine delivery systems (ENDS) advertising. The goal of Phase 2 of this research is to understand how ENDS design features including flavors are presented in advertising content, as well as how nicotine and its concentration/volume/mass and type (nicotine or nicotine salts, for example) are depicted/communicated in ads. Researchers will purchase ENDS advertisements and their associated spend data (i.e., cost per ad) for 2018-2020 from a media tracking service. The sample will include ENDS ads from magazines (consumer and business-to-business), newspapers, radio, television, out-of-home (e.g., billboards, point-of-sale), and electronic media (e.g., direct-to-consumer emails, online displays, banner ads). Researchers will then content-code the ads for features, focusing on how flavors and nicotine are presented, including written and visual content; ads will also be coded for the prevalence and content of health warnings. Results across all ad years of the Phase 1 and Phase 2 study periods (2015-2020) will be combined. Researchers will analyze the depiction of flavor and nicotine content by advertisement medium over time, the depiction of flavor and nicotine content by medium audience, and marketing investments by manufacturer, brand, advertising medium, and products (including flavor and nicotine features). Researchers will also assess the presence and content of health warnings now required in ENDS advertisements. Findings of this study may be used to inform future regulatory activities related to ENDS marketing.

CTP Supplement to Parent Grant: Assessing the Intended and Unintended Consequences of E-cigarette TV Advertising

This proposed administrative supplement will build upon the parent project, titled “Assessing the Intended and Unintended Consequences of E-cigarette TV Advertising”, to leverage resources and infrastructure to investigate how a newly authorized heated tobacco product, IQOS, will be marketed in Atlanta, GA, the first test market for IQOS in the U.S. Study aims are: (1) to monitor and conduct surveillance of IQOS marketing in retail stores and public events in Atlanta, and IQOS marketing on social media, print media, and via direct mail/email; and (2) to analyze the content of IQOS marketing to determine whether it may target or appeal to tobacco disparity populations defined by gender, age, race/ethnicity, sexual orientation and socioeconomic status. Findings may inform regulatory activities related to heated tobacco products, particularly those related to youth and other priority populations.

CTP Supplement to Parent Grant: The Impact of Design Characteristics on the Modification Potential of Electronic Nicotine Delivery Systems

The goal of this project is to study early adopters of the IQOS heated tobacco product in Atlanta, Georgia by assessing their knowledge, risk perceptions, exposure to marketing, tobacco use history, and reasons for using IQOS; studying their IQOS use experience and behaviors, including dual or poly use with other tobacco products; and investigating their sociodemographics to understand the characteristics of early IQOS adopters. Study aims are: (1) to examine reasons for purchase, use intentions, risk/harm and benefit perceptions, knowledge about tobacco products, marketing exposure, tobacco use history, and sociodemographics among early adopters of IQOS in the greater Atlanta area, and (2) to conduct an in-depth examination of the IQOS retail experience, marketing exposure, and product use behaviors among IQOS early adopters, including experience with using IQOS, patterns of use, and dual or poly use with other tobacco products. To achieve Aim 1, researchers will conduct 400 intercept surveys within the first six months of product release among a convenience sample of adult (aged 18+) consumers who purchase IQOS at the IQOS store at Lenox Square and other Atlanta area retail stores that sell lQOS products. To achieve Aim 2, researchers will conduct six focus groups among IQOS early adopters (three among 20 young adults aged 18-29 and three among 20 adults aged 30+). Findings will provide information about early IQOS adopters.

CTP Supplement to Parent Grant: Evaluating Concomitant Use of Very Low Nicotine Content Cigarettes and E-cigarettes Among Daily and Non-Daily Smokers on Abuse Liability

In this supplement to an existing study titled “Evaluating Concomitant Use of Very Low Nicotine Content Cigarettes and E­cigarettes Among Daily and Non-Daily Smokers on Abuse Liability,” researchers will add a third arm to the study: one that exposes 80 adult daily cigarette smokers (aged 21 and older) to high and low nicotine dose JUUL e-cigarettes, along with very low nicotine content cigarettes (VLNCCs). Parent study aims are: (1) to characterize the effects of dual use of VLNCC and e-cigarettes on abuse liability, nicotine compensation, and product use, liking, and relative reinforcing efficacy among 80 adult daily smokers; (2) to characterize the effects of dual use of VLNCC and e-cigarettes on abuse liability, nicotine compensation, and product use, liking, and relative reinforcing efficacy among 80 adult intermittent smokers; and (3) to characterize the effects of dual product use on abuse liability as measured by retrospective measures, smartphone daily diary, and real-time measures captured via smartphone ecological momentary assessment. The study is obtaining information about the effects of dual use of VLNCCs and e-cigarettes with differing levels of nicotine on nicotine abuse liability, as measured by nicotine compensation, product use and liking, relative reinforcing efficacy, and assessments of withdrawal, craving, affect and satisfaction. In the parent study, smokers are provided with eGo-T e-cigarettes, which are second-generation devices; given the growth in market share of JUUL, researchers will add a third study arm that will use the same design and measures as existing study arms but will expose smokers to JUUL e-cigarettes rather than the eGo-T product. Findings may inform regulatory activities related to JUUL products.

Tobacco Longitudinal Mortality Study

The Tobacco Longitudinal Mortality Study (TLMS) will examine tobacco use and associated mortality in a large national sample of American households. Researchers will create a TUMS database using data from the Current Population Survey (CPS) Tobacco Use Supplements (TUS) (which includes 3 million individuals), the National Death Index (NDI), the Centers for Medicare and Medicaid Services (CMS), and other health agencies and researchers. Researchers will then link and analyze this data to estimate all-cause and cause-specific mortality outcomes including cardiovascular disease, stroke, heart attack, and respiratory disease (including chronic obstructive pulmonary disease (COPD)) associated with the use of cigarettes, cigars, pipes, hookah, and smokeless tobacco products. Finally, researchers will incorporate data from the National Cancer Institute to assess risks of lung, colorectal and breast cancer. Researchers will assess the mortality and cancer risk of common dual and poly-use patterns and may also examine the influence of tobacco cessation on total mortality, cause-specific mortality and cancer incidence. Findings will provide new information about the link between tobacco use and mortality.

Impact of Flavor on Youth & Young Adults use Intention, Abuse Liability and Perceptions of Cigarillos

The goal of this study is to examine the impact of characterizing flavors in cigarillos on product appeal, attention to marketing, product perceptions, abuse liability, and subsequent use behavior among youth (ages 14-20) and young adults (ages 21-28). Study aims are: (1) to evaluate perceptions of flavors on appeal, purchasing and risk perceptions of cigarillo products among young adult and adolescent cigarillo users; (2) to examine differences in visual attention and risk perceptions of flavored and unflavored cigarillo advertisements among young adult cigarillo users and nonusers; and (3) to evaluate, in an experimental tobacco marketplace, the abuse liability/addictive potential of flavored versus unflavored cigarillos while simultaneously evaluating the substitutability of flavored versus unflavored JUUL e-cigarettes. To achieve Aim 1, researchers will ask 392 youth and young adult cigarillo smokers to quantitatively rate the role of flavor and report perceptions of product appeal, health risk, advertising exposure and use intentions; participants will also complete purchase and substitution tasks. To achieve Aim 2, researchers will use eye tracking equipment to compare visual attention across a set of flavored only, unflavored only, or mixed advertisements for cigarillo products and JUUL in a randomized experiment involving 150 young adult and adolescent users and non-users; participants will provide absolute and relative risk perception ratings immediately and one week after advertisement exposure. To achieve Aim 3, researchers will randomly assign 162 young adult cigarillo users to one of four conditions in an experimental online store with different products available: (1) flavored cigarillos and fruit-flavored JUUL devices, (2) unflavored cigarillos and fruit-flavored JUUL devices, (3) flavored cigarillos and tobacco-flavored JUUL devices, or (4) unflavored cigarillos and tobacco-flavored JUUL devices; researchers will then evaluate purchasing behavior, price sensitivity, product substitutability, and motivation to quit. Findings may inform regulatory activities related to cigarillos.

Blood and Brain Based Biomarkers of Injury to Assess the Cerebrovascular Impact of Emerging Alternatives to Classic Cigarette Products

While traditional measures exist for assessing cardiovascular and respiratory health in response to the short- and long-term effects of tobacco smoking and, to a lesser extent, e-cigarette use, more data concerning the cerebrovascular toxicity of these products would be useful. The goals of this study are to investigate the impact of cigarette smoking vs. e-cigarette use on the brain microvascular environment; validate selected biomarkers associated with pro-thrombotic alteration of blood hemostasis (increased risk of stroke) and severity of post-ischemic brain injury in response to chronic exposure to tobacco smoking and/or e-cigarette use; and evaluate the relevance of selected biomarkers in assessing e-cigarette vs. tobacco smoking harm with respect to blood-brain barrier viability, neurovascular inflammation, onset of stroke, and stroke outcome. Study aims are: (1) to assess the cerebrovascular impact of e-cigarette vaping and JUULing vs. tobacco smoking in mice and develop potential biomarkers to determine harm/toxicity; and (2) to evaluate and validate the impact of chronic exposure to e-cigarettes and JUUL vs. tobacco smoking on the risk of stroke, secondary brain damage, and post-ischemic neurological impairments in mice. To address Aim 1, researchers will compare the harm/toxicity of vaping/JUULing vs. tobacco smoking on the blood-brain barrier and will evaluate potential biomarkers of harm. To address Aim 2, researchers will compare the impact of tobacco smoking and vaping/JUULing on brain vascular damage, focusing specifically on the impact on stroke risk and outcomes using brain and blood-based biomarkers specific to inflammation, hemostasis and antioxidative response that were evaluated in Aim 1. Findings may inform regulatory activities related to cigarettes, e-cigarettes, and JUUL.

Physical and Chemical Characterization of Aerosols Produced by Nicotine Salt Based E-Liquids

E-liquids containing nicotine salts of volatile organic acids can deliver nicotine more rapidly and efficiently than traditional free-base nicotine formulations. Manufacturers have incorporated this formulation into electronic nicotine delivery systems (ENDS) production, and nicotine salt-based products (led by JUUL) now have a major share of the U.S. ENDS market. More information regarding the chemical and physical characteristics of nicotine salt-based ENDS would be useful, specifically related to how nicotine salt aerosols differ from those produced by other nicotine formulations, which characteristics may influence nicotine delivery, and whether nicotine salt aerosols have a different profile of harmful and potentially harmful constituents (HPHCs). The goal of this project is to provide comparative data on the aerosol characteristics and HPHC profiles of nicotine salt and free-base nicotine ENDS. Researchers will develop and validate a set of analytical methods that will physically and chemically characterize nicotine salt e-liquids and the aerosols produced by both nicotine salt and free-base nicotine e-liquids. Findings will provide information about how nicotine formulation affects nicotine delivery and HPHC emissions.

Respiratory Effects of E-Cigarette Use Among Youth: A Prospective, Longitudinal Investigation

More information about the acute and chronic pulmonary and respiratory effects of e-cigarettes would be useful. The goal of this study is to investigate pulmonary functioning and respiratory effects among 150 youth aged 15-17 years, 100 of whom are exclusive-e-cigarette users and 50 of whom are never-users. Study aims are: (1) to compare changes over one year in pulmonary functioning and respiratory health between exclusive e-cigarette users and never-users in repeated laboratory sessions; and (2) to identify a dose-response relationship between quantity/frequency of e-cigarette use (via daily self-monitoring on a mobile phone app) and acute changes in pulmonary functioning (via same-day, home-based spirometry measurements). To achieve Aim 1, subjects will complete one baseline and four subsequent laboratory assessments over one year to provide a comprehensive assessment of respiratory health (e.g., airway reactivity, airway inflammation, pulmonary functioning). To achieve Aim 2, subjects will track their e-cigarette use by using a mobile phone app and take home-based spirometry measurements daily for four two-week periods (one prior to each laboratory assessment) so that the immediate acute effects of e-cigarette use on respiratory markers can be tracked. Findings may inform regulatory activities related to e-cigarettes.

Modeling the Impact of Flavor Bans Among Young Adult Tobacco Users Using Discrete Choice Experiments and Agent-Based Modeling

The goal of this study is to examine the impact of two flavor ban alternatives on young adults (aged 18-34) who are recent (past 30-day) users of tobacco products including electronic nicotine delivery systems (ENDS). Products studied will include menthol cigarettes; flavored cigars, cigarillos, and little cigars; and menthol and non-menthol flavored ENDS. Study aims are: (1) to assess product switching after implementation of a flavor ban and examine related determinants; (2) to estimate consumer response to hypothetical flavor bans using discrete choice experiments; and (3) to examine the impact of flavor ban policies using agent-based models. To address Aim 1, researchers will conduct an online survey among 600 young adult tobacco/ENDS users to assess product switching behavior after implementation of a flavor ban in San Francisco; researchers will evaluate flavor ban compliance enforcement, examine switching patterns, and analyze the determinants of changes in product use. To address Aim 2, researchers will conduct online discrete choice experiments with 600 young adults to estimate the impact of hypothetical flavor bans on product demand. They will examine multiple flavor ban policies related to menthol cigarette and flavored ENDS and will estimate the effects of product, flavor, price, nicotine content, and perceived harmfulness on smoker/user behavior. To address Aim 3, researchers will develop simulation models that capture the key determinants of switching behaviors and use the models to examine the impact of various flavor ban policies on switching behaviors as well as conversations between tobacco retailers and consumers. Researchers will also examine additional intervention strategies (price/tax policy, mass media campaign, smoking cessation program) that may work in concert with flavor ban policies. Findings will provide new information about the effects of tobacco product flavor bans on young adult use behavior.

Randomized Trial of Low Nicotine Cigarettes Plus Electronic Cigarettes in Smokers with a Mental Health Condition

Individuals with mental health conditions are particularly vulnerable to tobacco use. The goal of this project is to determine the likely health effects of use of very low nicotine content (VLNC) cigarettes, in conjunction with availability of nicotine-containing e-cigarettes, in adult smokers (aged 18-65) with mental health conditions. Study aims are: (1) to determine whether smokers with mental health conditions have lower levels of markers of harm (e.g. urine NNAL, carbon monoxide [CO]), measures of mental health, and cigarette addiction when switched to VLNC cigarettes for 16 weeks, as compared with normal nicotine content cigarettes (NNCs); (2) to determine whether smokers with mental health conditions have lower levels of markers of harm and cigarette addiction when provided with nicotine-containing (15mg/ml) versus zero nicotine e-cigarettes in order to switch to e-cigarettes or lower their cigarette consumption; and (3) to determine whether use of VLNCs increases the proportion of smokers who completely switch away from combustible tobacco use, as assessed four weeks after the end of the randomized phase of the trial. Researchers will randomize 240 smokers with mental health conditions to one of four groups: (1) NNCs (11mg nicotine/cigarette) and 15 mg/mL nicotine e-cigarettes; (2) NNCs and zero mg/mL nicotine e-cigarettes; (3) VLNCs (0.2 mg nicotine/cigarette) and 15mg/mL nicotine e-cigarettes; and (4) VLNCs and zero mg/mL nicotine e-cigarettes. Subjects will be followed for 16 weeks on study products and then another four weeks thereafter. At the end of the 16-week phase, participants will attend their last visit, receive encouragement to quit all tobacco products, and notified of community resources where they can receive smoking cessation counseling. Participants will be asked to provide information about their intentions for ongoing tobacco product use or cessation and will be followed for four weeks to assess these outcomes; those claiming to be no longer using combustible tobacco products will be visited to verify with a measure of exhaled CO. Study findings may inform regulatory activities related to VLNCs.

SmartVape: Real-Time Assessment of ECIG Device Characteristics using a Smartphone App

Most e-cigarettes use an electrically-powered heater to aerosolize a liquid that usually contains nicotine, a solvent (i.e., propylene glycol and/or vegetable glycerin), and flavorants. The power of the e-cigarette device, which is based on the device’s operating voltage and heater resistance, varies across devices and is a major determinant of how much nicotine and other toxicants are aerosolized. The goal of this study is to develop a tool to assess e-cigarette power objectively in real-world settings. Study aims are: (1) to standardize methods for e-cigarette and e-liquid image capture; (2) to develop the SmartVape app and supporting software; and (3) to test the app’s usability and data quality in real-world conditions. Researchers will develop a smartphone app (SmartVape) designed for e-cigarette users to capture images of their devices and e-liquid. On a back-end server, an operator will be able to compare these images to an image-based product registry with known data on device characteristics and e-liquid nicotine content. The result will be the ability to assess accurately the device used and the amount of liquids consumed over a discrete time period. With this information, researchers will be able to estimate nicotine intake from e-cigarettes more accurately in real-world settings. To address Aim 1, researchers will recruit 200 adult (aged 18+) e-cigarette users who will bring all of their e-cigarette devices and e-liquids to a laboratory, where the devices will be measured and photographed. To address Aim 2, researchers will develop the app and the image-based product registry. To address Aim 3, 50 adult e-cigarette users will use the app to record the devices and liquids they use over a 14-day period. The tool will provide a feasible and objective method for assessing e-cigarette device and e-liquid characteristics in surveillance research.

Correcting Public Misperceptions About Very Low Nicotine Content Cigarettes

In July 2017, FDA announced a comprehensive approach to tobacco and nicotine regulation that includes moving toward a very low nicotine content (VLNC) standard for cigarettes. The goal of this study is to reduce unintended consequences of a VLNC policy by developing campaign messages that address the common public misperception that VLNC cigarettes are safer to smoke than normal nicotine content cigarettes (a misperception that could potentially lead to lower quit rates). Study aims are: (1) to develop communication campaign messages that address the misperception that VLNC cigarettes are less likely to cause cancer than current cigarettes; and (2) to determine whether selected campaign messages reduce this misperception. Researchers will first develop 24 potential campaign messages and will obtain feedback from a panel of communication experts to refine the messages. Next, they will conduct an online experiment in 1,000 adult (ages 18 and older) smokers to identify the six most effective messages; conduct six focus groups, each with 8-10 adult smokers, to obtain feedback about the six messages; and work with the expert panel to select three messages for evaluation. They will then conduct an online experiment with a nationally representative sample of 1,096 adult smokers to understand the extent to which the three campaign messages reduce VLNC misperceptions and increase motivation to quit if a VLNC standard is enacted. Study findings may inform communication campaigns about VLNC cigarettes.

Investigation into Waterpipe Physical Design Parameters’ Effects on HPHC yields in Smoke and Charcoal Emissions (Phase II)

The goal of this project is to investigate the relationship between waterpipe physical parameters and harmful and potentially harmful constituent (HPHC) yields. Researchers will methodically isolate and alter individual waterpipe physical parameters (e.g., hose length; stem length, stem depth in water) and determine how these parameters affect yields of HPHCs such as quantities of aldehydes, metals, nicotine, tobacco-specific nitrosamines (TSNAs), and volatile organic compound (VOC) levels in waterpipe tobacco smoke. Phase II of this project seeks to determine how waterpipe dimensions affect waterpipe tobacco smoke chemistry and explores the need for a standardized testing waterpipe. Findings may provide new information about a standard waterpipe design for waterpipe tobacco product testing.

Impact of Flavors on Nicotine Perception and Self-Administration via E-cigarettes

Mechanisms by which flavors impact the initiation and maintenance of tobacco use are not well understood. Existing evidence suggests that flavors may enhance the appeal of and facilitate the development of addiction to tobacco products by influencing nicotine’s reinforcing or aversive actions. The goal of this study is to examine whether menthol and fruit flavors impact e-cigarette use through specific behavioral mechanisms and exert different effects across nicotine concentrations. Study aims are to assess the impacts of nicotine and flavor (and their interactions) on participants’ subjective ratings of different e-liquids and the cumulative amounts of self-administered e-liquids. Fifty young adults (ages 18-30 years) will be asked to attend four test sessions each. Each test session will consist of two components. During the first component, subjects will use five different e-cigarettes and will be directed to take two 4-second puffs at 15-second intervals for each e-cigarette, with a 5-minute break between each e-cigarette. Subjects will be asked to self-administer a total of 12 puffs of the e-cigarette across approximately half an hour. They will be asked to report subjective effects for each e-cigarette during the 5-minute breaks using the Drug Effects Questionnaire (DEQ). In the second component, subjects will be given access to the same five e-cigarettes and be allowed to use them as they choose for 45 minutes in total; researchers will track number of puffs. The sessions will be identical except that the e-liquids in the e-cigarettes will differ between sessions. The subjects will use 20 e-liquid types across the entire study (4 test sessions x 5 e-liquid conditions per session) and the e-liquids will vary by flavor (unflavored, menthol, menthol mint, green apple, watermelon) and nicotine level (0, 6, 12, 24 mg/ml nicotine). The order of flavors and nicotine levels will be randomly assigned to each subject and neither the subject nor the researcher will be told the order. This study will provide new information about the impact of flavors on e-cigarette use.

Impact of Cigar Flavor on Tobacco Use Behaviors and Addiction in Dual Users

The rapid increase in dual use of flavored little cigars/cigarillos (LCCs) with cigarettes among U.S. young adults has significant implications for their health, addiction, and cessation. The goal of this study is to determine the addiction potential of flavored and unflavored LCCs compared with cigarettes, and if addiction potential varies by flavor and sex, among young adult (ages 18-34) dual users. Study aims are: (1) to characterize the addiction potential of LCCs compared with cigarettes; (2) to determine the extent to which the addiction potential of LCCs varies by flavor and sex of user; and (3) to determine the extent to which flavoring affects LCC use in the natural environment. The study will be conducted over three weeks with 145 young adult dual users of cigarettes and LCCs. Participants will be asked to substitute preferred flavor LCCs for one week and unflavored LCCs for one week in place of their normal LCCs. The study will include survey-based measures and ecological momentary assessments (EMAs) of addiction potential, dependence, and tobacco use, and biomarkers of exposure (exhaled carbon monoxide and urinary cotinine). Addiction potential of cigarettes and LCCs will be characterized by behavioral economic indices of demand (such as hypothetical consumption at escalating prices) and other standardized measures to address Aims 1 and 2. Participants will record their tobacco use, craving, mood, and setting using EMA on their mobile phones to address Aim 3. This study will provide new information about LCCs that may inform regulatory activities.

Understanding the Association Between Electronic Cigarette Aerosol Emissions, Tobacco Product Characteristics and User Topography and Consumption Behavior

There is a lack of consensus regarding appropriate metrics for reporting e-cigarette emissions. The total particulate mass concentration, CTPM, of whole aerosol emissions is dependent upon both user topography behavior and e-cigarette/e-liquid product characteristics; the mass ratio of harmful and potentially harmful constituents (HPHC) (fHPHC) and nicotine (fNic) present in aerosol emissions are different functions of topography behavior and product characteristics. The researchers propose a theoretical framework that defines the product of the two terms as HPHC mass concentration: CHPHC [mg/mL] = fHPHC [mg/mg] x CTPM [mg/mL]; similarly, for nicotine, CNic [mg/mL] = fNic [mg/mg] x CTPM [mg/mL];. The goals of this study are to use this framework to develop a standardized test protocol for e-cigarettes and e-liquids, propose standardized emissions outcome measures, and inform the development of criteria to distinguish low- and high-dose ENDS. Study aims are: (1) to conduct screening studies of 24 e-cigarette products and 8 e-liquid compositions to inform the creation of a formal, standardized e-cigarette emissions test protocol; (2) to evaluate total particulate mass concentration as a function of product characteristics and user topography behavior; and (3) to evaluate HPHC and nicotine mass ratio of emissions present in whole aerosol as a function of product characteristics and user behavior characteristics. Findings may inform standardized testing processes for e-cigarette emissions.

Differences in Inflammation, Cardiovascular Risk Factors and Respiratory Health with Use of Menthol Cigarettes: Informing the Regulation of Tobacco Flavorings to Protect Public Health

There is limited information regarding potential differences in cardiovascular risk factors or respiratory health with menthol cigarette use. The goal of this project is to evaluate differences in systemic inflammation, cardiovascular risk factors, and respiratory health with use of menthol cigarettes among US smokers. Researchers will use interview, physical examination, and biological specimen data from 9,880 adult current smokers who participated in the National Health and Nutrition Examination Survey (NHANES), a series of nationally-representative surveys of the US population, from 1999 through 2016. Study aims are to evaluate the associations between menthol compared to nonmenthol cigarette use by analyzing: (1) markers of systemic inflammation (C-reactive protein, fibrinogen, white blood cell count, and homocysteine); (2) cardiovascular risk factors (hypertension, diabetes, and reduced kidney function); and (3) respiratory health outcomes (fractional exhaled nitric oxide levels, spirometry-defined pulmonary impairment, past year wheeze, and frequent cough and frequent phlegm). Findings may inform regulatory activities related to menthol cigarettes.

Mitochondrial Genetic Alterations: A Clinical Trial of a Standardized Research E-cigarette

E-cigarettes may have the potential to reduce harm for current smokers, but additional research on target organ toxicity (e.g., the respiratory tract) would be useful. This study will focus on the effects of e-cigarette use on mitochondrial DNA (mtDNA) in the lung and nasal tract. Researchers will use bronchoscopy to evaluate the lungs of smokers who are switched to e-cigarettes, namely the National Institute on Drug Abuse (NIDA) Standardized Research E-cigarette (SREC). In this study, 96 smokers aged 21-45, following baseline bronchial and nasal brushings, will be randomized to continue smoking their usual brand (control group), completely switch to the SREC, or receive nicotine replacement therapy (NRT). A follow-up bronchial and nasal brushing will be done after two months of use. Study aims are: (1) to assess changes in mtDNA genetic features (mutations and copy numbers) in the bronchial and nasal epithelium of smokers randomized to continued smoking, exclusive e-cigarette, or NRT use; (2) to investigate whether changes in mtDNA alterations are associated with lung inflammation and gene expression; and (3) to compare mtDNA alterations between bronchial and nasal samples. This study will determine the extent to which mtDNA alterations as a biomarker of harm are reduced following the use of e-cigarettes and provide evidence for the use of nasal epithelium for noninvasive biomarkers of harm.

Electronic Cigarette Cardiotoxicity Varies by Flavorings: What Can We Learn from Mice?

More information about the potential pulmonary toxicity of e-cigarette flavorings would be useful. The goal of this study is to evaluate whether long-term (three-month) inhalation exposure of adolescent mice to flavored e-cigarette aerosols leads to changes in pulmonary blood vessels (vasculature) — such as inflammation, pulmonary remodeling, artery thickening, and increase in right ventricular systolic pressure — that predispose adult male and female mice to pulmonary hypertension. Researchers selected flavors (vanilla, cinnamon, menthol, double apple hookah, and peach schnapps) based on human usage and published diacetyl levels. The study aim (with multiple sub-aims) is: (1A) to determine whether three-month inhalation exposure of adolescent mice to e-cigarette aerosols (with or without flavorings) produces changes in pulmonary vasculature; (1B) to investigate the time course of effects by examining changes associated with the development of pulmonary hypertension and/or emphysema on days 30, 60, and 90; and (1C) to determine persistent effects 90 days after cessation of the three-month exposure. Study findings may inform regulatory activities related to flavored e-cigarettes.

Oxidant Exposure and Related Harm from Tobacco Smoke

Oxidants are a major class of toxicant in tobacco smoke and likely play a critical role in the development of tobacco-related diseases including chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), and cancer by causing oxidative stress/damage and inflammation. However, the specific oxidants most responsible remain unclear. The goals of this project are to identify specific oxidants responsible for tobacco-related harm and determine the impact of oxidant reduction on tobacco-related toxicity endpoints. Study aims are: (1): to determine the levels and identity of free radicals and other oxidants delivered by different combustible tobacco products/brands using advanced electron paramagnetic resonance (EPR) spectroscopy and liquid chromatography-tandem mass spectrometry (LC-MS/MS) methodologies; (2) to determine the impact of tobacco smoke oxidants on lung damage and inflammation, comparing effects of high vs. low oxidant brands and tobacco varieties, in mice; and (3) to determine the impact of charcoal filtration of cigarette smoke on oxidant-induced lung damage in mice. Findings will reveal new information on the toxicological importance of oxidant exposure.

Impact of New Standards for Tobacco Products among Dual E-cigarette/Combusted Cigarette Users

Dual users of e-cigarettes and combusted cigarettes comprise 40% of multiple tobacco product users. The goal of this research is to evaluate the potential effects of limiting e-cigarette/e-liquid flavors to tobacco-only on preference for combusted cigarettes. In this study, 280 adult dual users (aged 18 and older) will undergo preference sessions during which they will make choices between an e-cigarette and a combusted cigarette. Study aims are to evaluate users’ self-reported anticipated choices if e-liquid flavors would be limited to tobacco only on: (1) choices for usual brand cigarettes; (2) choices for menthol and non-menthol cigarettes (among menthol-preferring participants); and (3) choices for cigarettes with normal nicotine content versus very low nicotine content. Findings may inform regulatory activities related to product standards.

The Role of E-cigarette Characteristics and Constituents in Cardiac Dysfunction

The acute and chronic health effects of e-cigarettes are mostly unknown. The goal of this project is to identify specific e-cigarette device characteristics and constituents associated with cardiac toxicity. Researchers will conduct electrocardiogram (ECG) and programmed stimulus electrophysiology (EP) studies in mice to test the hypothesis that e-cigarettes induce electrical disturbances in the heart that are related to e-cigarette characteristics and constituents. Study aims are: (1) to determine how device characteristics influence the acute electrophysiologic effects of e-cigarettes in mice, and (2) to assess the impacts of chronic e-cigarette exposure on cardiac electrophysiology and hemodynamics. Real-time cardiac physiology will be monitored during and after acute exposures to aerosols of e-cigarettes with various characteristics (device type, user settings, nicotine levels) to determine how they affect both harmful and potentially harmful constituent (HPHC) production and ECG measures of cardiac dysfunction. The device characteristics with the greatest and smallest acute cardiac effects will be selected for chronic exposure studies that will comprehensively assess cardiac EP and hemodynamics. E-cigarette exposure groups will be simultaneously compared to cigarette smoke and filtered-air exposure groups. This study will present new data regarding the relative cardiac toxicity of different e-cigarette devices, constituents, and settings, particularly with regard to their potential to cause cardiac arrhythmia.

Impact of Novel Heat-not-Burn Cigarettes on Pulmonary Inflammation and Immunity

More information about the impact of heat-not-burn (HnB) aerosols generated from a product called IQOS on pulmonary inflammation and immunity to pathogens that cause respiratory diseases would be useful. The goal of this project is to determine whether HnB aerosol inhalation results in pulmonary damage and suppresses the immune response to respiratory infection and vaccination. Researchers will compare the potential effects of HnB aerosol inhalation exposure to effects caused by cigarette smoke and e-cigarette aerosols in both male and female mice. Study aims are: (1) to evaluate whether chronic inhalation exposure to HnB aerosol has the potential to cause lung inflammation and prompt changes in inflammatory cell numbers and cytokine levels in the lung, thereby altering the innate immune response; (2) to evaluate whether chronic inhalation of HnB aerosol creates an environment in the lungs that has the potential to impair adaptive immune responses to a vaccine and reduce the ability to overcome infection in the lung; and (3) to evaluate whether transition to HnB use following tobacco smoke exposure hinders the reduction in pulmonary inflammation and immune suppression that could be achieved by true cessation. Findings will provide new insights on the health risks of HnB products.

The Impact of E-Cigarette Advertising and Warning Labels on E-Cigarette Use Behavior in Adolescents

Images of sweet/fruit flavors on e-cigarette advertisements may distract youth from health warnings. To better understand how these factors impact youth e-cigarette use, researchers will use functional magnetic resonance imaging (fMRI) and eye tracking to link neural responses to e-cigarette advertising and health warnings to future e-cigarette use in 80 adolescents aged 14-17 years. Participants will view e-cigarette advertisements and health warnings and complete quarterly follow-up surveys for one year. Medial prefrontal cortex (MPFC) and nucleus accumbens (NAc) activity will be measured and tested for relationships with future e-cigarette attitudes, intentions and use. Researchers will also test the specific impact of different categories of health warnings and different flavors and the interactions between these factors, including impact on memory of health warnings. Study aims are: (1) to test the hypothesis that greater MPFC activity as adolescents view e-cigarette health warnings will be related to more negative e-cigarette attitudes and intentions and lower use of e-cigarettes in the next year; (2) to test the hypothesis that greater NAc activity as adolescents view e-cigarette advertisements will be related to more positive e-cigarette attitudes and intentions and greater use of e-cigarettes in the next year; and (3) to compare the relative value of multiple measures –fMRI, eye tracking and surveys — to predict future e-cigarette use in the next year. This project will generate evidence on the impact of e-cigarette advertising and health warnings on youth e-cigarette use and may inform regulatory activities related to flavors, labeling and marketing.

Age of Initiation of Tobacco Products Among USA Youth and Young Adults

Estimating the age of onset of tobacco product initiation, transition or trajectories of patterns of use, and correlates of use among U.S. youth and young adults could be informative. This study involves a prospective secondary analysis of the first three waves of the Population Assessment of Tobacco and Health (PATH) Study among U.S. youth (aged 12-17 years) and young adults (aged 18-24 years) who reported never use at Wave 1. Use of the following tobacco products will be analyzed: cigarettes, e-cigarettes, cigars (traditional cigars, cigarillo, filtered cigars), hookah, and smokeless tobacco. Seven outcomes will be evaluated for each product: age to first report ever or past 30-day use, age to become susceptible to use, age to be an established user (i.e. ever use fairly regularly), age to first report dual/poly use, age to report first use of a flavored product, and age of ever combustible use. Study aims are: (1) among youth who were never users at Wave 1, to estimate their age of initiation of tobacco products and to identify the risk factors associated with age of initiation of each product; (2) among young adults who were never users at Wave 1, to estimate their age of initiation of tobacco products and to identify the risk factors associated with age of initiation of each product; and (3) among all participants, to identify trajectories and transitions in the onset of tobacco product use across time and to identify associated risk factors. Researchers will explore socio-demographic, interpersonal, intrapersonal, social, and environmental factors potentially associated with the age of initiation of the different products. This study will provide new data regarding tobacco product use trajectories among youth and young adults.

Understanding the Real-World Impact of the Use of Three Alternate Nicotine-Delivery Products on Combustible Cigarette Use

In this study, researchers will examine how well e-cigarettes and very low nicotine content cigarettes (VLNCs) substitute for combustible cigarettes in real-world settings and whether this is influenced by nicotine patch use. Study aims are: (1) to examine the ability of VLNCs, e-cigarettes, and no alternative product to substitute for smokers’ usual cigarettes in real-world settings and whether these effects are influenced by nicotine replacement; and (2) to examine the effects of VLNC, e-cigarette, and no alternative product use on the use of study products and the underlying mechanisms that drive such use and whether these effects are influenced by nicotine replacement. Researchers will randomly assign 180 daily smokers aged 18 and older who are not planning to quit smoking to one of three study conditions: VLNCs, Juul e-cigarettes, or no alternative product. Participants will have access to these products for four weeks. During two different weeks, participants will be asked to switch from their usual cigarettes and use only their assigned study product. They will also be asked to use either a nicotine or placebo patch. Participants will record each time they use their own cigarettes or the alternative product in real time via a smartphone, and, for some use events, answer questions about the use context (e.g., affect, smoking permitted) and possible mechanisms driving use behavior (e.g., withdrawal alleviation, taste, satisfaction). Researchers will also examine the impact of factors such as sex, dependence, psychiatric comorbidity, and risk perceptions on use behavior. Findings may inform regulatory activities regarding e-cigarettes and VLNCs.

Investigation into Waterpipe Regimen Effects on HPHC Yields in Smoke and Project Title Charcoal Emissions (Phase l)

The goal of this project is to investigate the relationship between waterpipe smoking regimen parameters and harmful and potentially harmful constituent (HPHC) yields. Researchers will methodically isolate and alter waterpipe smoking regimen parameters (e.g., puff duration, puff volume, interpuff interval) and determine how these parameters affect yields of HPHCs such as quantities of aldehydes, metals, nicotine, tobacco-specific nitrosamines (TSNAs), and volatile organic compound (VOC) levels in waterpipe tobacco smoke. Phase I of this project focuses on the way waterpipes and waterpipe tobaccos are smoked and seeks to determine how these parameters affect waterpipe tobacco smoke chemistry. Findings may provide new information about intense and non-intense smoking regimens for waterpipe tobacco product testing.

Analysis of Tobacco Filler/Matrix-Specific HPHCs

The goal of this study is to identify which of the 93 harmful and potentially harmful constituents (HPHCs) identified by the FDA are present in tobacco products currently marketed in the U.S. Researchers will use validated analytical testing methods to conduct qualitative and quantitative analyses on 27 brands of cigarette tobacco fillers, 24 brands of roll-your-own tobacco fillers, 27 brands of smokeless tobacco fillers, and 21 brands of waterpipe tobacco fillers. Findings may inform regulatory activities regarding HPHCs.

Identification and Validation of a Biomarker of Electronic Cigarette Exposure

The goal of this study is to identify and confirm a biomarker specific to e-cigarette use and secondhand exposure. Study aims are: (1) to confirm that the exact oligomer compounds formed by the thermal degradation of propylene glycol (PG) and vegetable glycerin (VG) are unique to e-cigarettes and not common in other tobacco products; and (2) to determine whether these chemicals or their metabolites are found in urine and/or blood specimens of e-cigarette users and bystanders who experience secondhand exposure. Researchers will confirm the chemical structure of the VG and PG oligomers formed during e-cigarette use. This information will guide a review of the literature to identify metabolites and metabolic pathways in urine and adducts in blood specimens and to inform the selection of the most appropriate biospecimen analytical approach. Researchers will then collect and analyze blood (serum and plasma) and urine from 63 e-cigarette users, conventional cigarette smokers, and non-users (ages 18 and older) to determine whether the biomarker is unique to e-cigarette users and present at measurable concentrations in the aerosol produced from 20 e-liquids. Upon agreement from FDA that a biomarker unique to e-cigarette aerosol has been identified, researchers will proceed with additional experiments to develop an empirical model that predicts the mass of the biomarker produced per puff. This model will correlate e-cigarette use with biomarker intensity in the biospecimens collected as part of a later study of e-cigarette user exposure and secondhand exposure. Study findings may provide the identification of a unique biomarker of e-cigarette use to be used in epidemiological and clinical studies that evaluate the acute and chronic health effects from e-cigarette use and secondhand exposure.

Developing Brand and Creative Concepts Designed to Prevent AI/AN Youth Tobacco Use

FDA Center for Tobacco Products (CTP) will conduct formative research to inform the development of messaging and creative concepts for a tobacco prevention campaign targeting American Indian/Alaska Native (AI/AN) youth. Researchers will conduct 12 focus groups with up to 16 AI/AN youth ages 13-17 per group who are either experimental cigarette users or at-risk non-triers. Participants will be recruited through community-intercept recruitment. Focus group activities will include individual surveys and discussions to gain insight into youth perceptions related to local teen culture, tobacco use trends, tobacco-related facts, and campaign brands and creative concepts to inform campaign development. Findings will inform the development of an AI/AN tobacco public education campaign.

Development of a Multi-pathway Physiologically Based Pharmacokinetic (PBPK) Model for Nicotine in Humans

In this study, researchers will build a computational tool to characterize nicotine pharmacokinetics in humans. This tool will include databases, referenced literature, and a multi-pathway physiologically-based pharmacokinetic (PBPK) model. In addition, the Population Assessment of Tobacco and Health (PATH) Study human nicotine and metabolite biomarker data, and potentially behavioral and physiological response profiles established in animal models, will be included. Overall, this model will be used to evaluate the nicotine exposure-response relationship across tobacco product types and user populations. The model will also be incorporated with other existing software to predict lung deposition of nicotine via inhalation exposure from tobacco product use. This computational tool may be used to inform regulatory science efforts.

Experimental Study to Test Acute Nicotine Toxicity Warnings for E-Liquids on Consumer Knowledge and Perceptions

The goal of this study is to assess the effectiveness of draft acute nicotine toxicity warnings for e-liquids in promoting consumer awareness and understanding of nicotine toxicity due to exposure to electronic nicotine delivery systems (ENDS). Specific aims of this study are to evaluate the effect of acute nicotine toxicity warnings for e-liquids on: (a) consumer knowledge of the health effects of acute toxicity from e-liquid exposure; (b) consumer knowledge of precautionary storage and handling practices for products that contain e-liquids; and (c) consumer knowledge of what to do in case of accidental contact with e-liquids. The final study sample will include approximately 5,000 current ENDS users. This study will include both young adult (aged 18-24) and adult (aged 25-65) participants from an Internet panel. Findings may inform regulatory activities related to ENDS warnings.

E-Cigarettes – Relationship between Wicking Rate and Other ENDS Design Parameters

As e-cigarettes have evolved, new models have increased user control of device settings, including a variety of choices in atomizers, atomizer coils, wicks, and airflow settings. If the wicking rate is insufficient, all of these parameters combined can cause a “dry puff,” essentially burning the wick and leading to an increase in carcinogenic carbonyls and other harmful and potentially harmful constituents (HPHCs). Currently, no published studies directly measure wicking rate and isolate the effects of other ENDS design parameters (e.g., puff topography, wattage, coil configuration, preheat time, wicking material and amount) on wicking rate. The goal of this study is to understand the impact of each of these design parameters on wicking rate and eventual production of HPHCs. Findings may inform future regulatory activities related to e-cigarettes.

Toxicity and Carcinogenicity Profiling of Tobacco Products via Organ Microengineering and Systems Biology

The goal of this study is to advance our recently developed “Breathing-Smoking Human Lung-on-a-Chip” technology to determine the toxic effects of hookah tobacco smoke and e-cigarette emissions. In Phase 1 (18 months) of this project, we will develop a three-dimensional (3D) functional organomimetic human lung airway by combining organ-on-a-chip and 3D bioprinting technologies. The synthetic living human lung will then be validated for recreating physiological responses in vitro. In Phase 2 (6 months), we will enhance a smoking robot prototype by creating add-on modules that will generate fresh whole smoke/vapors from a diverse range of hookah tobacco and e-cigarette products; we will also use tubing with minimal adsorption properties to transfer gases and aerosols and upgrade the control software to execute e-smoking and waterpipe tobacco smoking topographies. In Phase 3 (18 months), we will integrate the lung airway with the smoking robot for system- and organ-level evaluation of tobacco products. We will expose the synthetic living human lung to freshly produced emissions of two different e-cigarette products and hookah tobacco from two commercial sources and examine pathological responses, including oxidative stress, inflammation, matrix remodeling, pH changes, nicotine absorption, and pre-neoplastic transformation at molecular, cellular, tissue and organ levels. Findings may inform future regulatory activities related to hookah and e-cigarette products.

Tracking Metals from E-cigarettes: From the Coil into Lung Tissue

E-cigarette devices may release nickel, chromium, lead, and other metals into the heated aerosol that may accumulate in lung tissue and blood. The goals of this study are to analyze the metal content of e-cigarette aerosol and to measure metal concentrations in lung tissue and blood using a mouse model of exposure. Study aims are: (1) to use Neutron Activation Analysis (NAA) to radiolabel various disassembled e-cigarette hardware components, followed by reassembly and measurement of the radiation energy spectrum of collected aerosol to identify specific sources of metal contamination; and (2) to conduct mouse exposure experiments to measure and analyze time- and dose-response relationships for nickel, chromium, and lead concentrations in lungs and blood following four-week exposure to e-cigarette aerosol. Findings will provide information about toxic metal exposures arising from e-cigarette use.

Emerging Chemicals of Concern in Evolving Electronic Nicotine Delivery Systems

Because electronic nicotine delivery systems (ENDS) contain plastic, glass and metal parts as well as e-liquids, they may contain a number of emerging chemicals of concern (ECCs), including phthalates, phenolic compounds, and flame retardants, that have been associated with adverse health outcomes such as asthma, endocrine disruption, reproductive and developmental abnormalities, and carcinogenic activity. The goal of this study is to characterize the types and levels of these chemicals in ENDS products, using various rigorous and reproducible analytical methods. Study aims are: (1) to characterize the contamination of e-liquids with ECCs by identifying the types and levels of ECCs in e-liquids; (2) to identify and measure the types and levels of ECCs in certain parts of ENDS, including refillable cartridge/tanks, as well as mouthpieces, which are potential ECC exposure sources; (3) to characterize thes types and levels of ECCs in ENDS aerosols; and (4) to examine and characterize the similarities and differences in types and levels of ECCs in e-liquids, extracted samples, and ENDS aerosols. Findings may inform future regulatory activities related to ENDS products.

The Exposure to Metals from E-Cigarettes (EMIT) Study

E-cigarettes expose users to metals, since a metal coil is used to generate aerosol and most coils are composed of nickel and chromium, which are known inhalation carcinogens. A new e-cigarette type called POD is growing in popularity with unknown potential for exposure. The goal of this study is to evaluate how e-cigarette use patterns impact exposure to toxic metals. Study aims are: (1) to understand the role of metal heating components on the transfer of metals into the aerosol, by analyzing metal concentrations in e-liquid before it is in contact with the heating coil, and in the aerosol generated; (2) to characterize patterns of e-cigarette use and other potential sources of metal exposures; and (3) to measure metals in blood, urine, saliva, and exhaled breath condensate of e-cigarette users, non-users, smokers and dual users, to evaluate how different patterns of e-cigarette and smoking use impact metal exposure. Researchers will assign 250 adults ages 18 and older to one of five groups: (1) 50 MOD e-cigarette users, (2) 50 POD users, (3) 50 cigarette smokers, (4) 50 dual users of e-cigarettes and combustible tobacco products, and (5) 50 non-users/non-smokers. All participants will answer a questionnaire on smoking history, e-cigarette use patterns, and work/hobbies that may involve metal use. Researchers will collect samples of blood, urine, saliva, and exhaled breath to measure and compare metal levels; samples of e-liquid and vapor will also be collected from e-cigarette users. Researchers will then use linear regression models to estimate the association of metals in biomarkers with e-cigarette use patterns, cotinine biomarkers, and metal concentrations in e-liquid and aerosol. Findings will provide new information about e-cigarette user exposure to metals and may inform regulatory activities related to e-cigarettes.

Assessing Toxicant Properties of Cigarillo and Hookah Aerosols in Lung Epithelial and Cardiac Cells Through Aerosol Exposure

The goal of this study is to evaluate the toxicant properties and predicted health effects of cigarillo and hookah tobacco products compared to cigarettes. Study aims are: (1) to characterize the hazardous chemicals linked to cancer and cardiopulmonary diseases in aerosols from eight common hookah tobacco products using standardized cytotoxicity, mutagenicity, and genotoxicity assays; (2) to evaluate complete and fractionated (particles and gas only) aerosols generated from cigarettes, cigarillos, and hookah products in lung epithelial cells, cardiac cells, and endothelial cells using short-term assays and biomarkers (cytokines, DNA adducts); and (3) to evaluate the adaptive responses of lung epithelial cells in response to treatment of cells for four weeks with aerosols from one of each type of tobacco product. Findings will indicate new information about the potential respiratory and cardiac health effects associated with cigarillo and hookah use.

Characterization of Potential Harm Caused by Electronic Cigarette Flavor Chemicals and their Reaction Products

The flavor chemicals and their degradation reaction products (generated by heating) in e-cigarette aerosols may cause cell toxicity. The goals of this project are to analyze commercial e-liquids to identify and quantify flavor chemicals and their degradation reaction products and to evaluate cellular responses. The researchers will test 550 popular refill and cartomizer fluids and 100 fluids that have been anecdotally reported to cause sickness in users using gas chromatography/mass spectrometry, liquid chromatography/mass spectrometry, and other analytical methods. Study aims are: (1) to understand the identities and concentrations of dominant flavor chemicals in e-cigarette refill fluids and heat-generated reaction products in aerosols; (2) to analyze 3D lung epithelial cells at the air liquid interface to identify and characterize their response to heat-generated aerosols containing high potency flavor chemicals; and (3) to evaluate the potency and biological effects of individual flavor chemicals and reaction products in aerosols generated without heating. Study findings may inform future regulatory activities related to e-cigarettes.

Studies Using the Tobacco Consumer Studies Panel – Topical Study B

This study is part of a larger contract to conduct a series of studies using the Tobacco Consumer Studies (TCS) Panel to research consumer reactions to tobacco-related information/communications and perceptions of tobacco products and their association with product use, intention, and behaviors; and consumer reactions (such as purchasing behaviors) to anticipated or actual changes in tobacco product availability and in tobacco product constituents. This study focuses specifically on free samples of tobacco products and tobacco product coupons participants may have received, how they received them, and where they redeemed them for tobacco products. The full TCS panel of approximately 4,000 tobacco users will be invited to take part in this study via web or mail. Researchers will conduct analyses to assess the prevalence of coupon and free sample receipt and use as well as details surrounding the receipt and use context (e.g., demographics, product type/brands, locations). Further analyses may explore the relationships between receipt of free samples/coupons and use behaviors, quit intentions, and harm perceptions.

Linking E-Cigarette Aerosol Characteristics to Mechanisms of Pulmonary Toxicity

The goal of this study is to understand how atomizer parameters and key ingredients in e-liquids contribute to undesirable aerosol characteristics and pulmonary toxicity. Study aims are: (1) to systematically vary e-cigarette device parameters (e.g., coil composition, coil resistance, applied voltage) and e-liquid components (propylene glycol, vegetable glycerin, nicotine, flavoring) to determine their impacts on aerosol physiochemical characteristics and in vitro toxicity; (2) to expose human airway epithelial cells to e-cigarette aerosols and determine toxicity signatures resulting from specific physiochemical features; and (3) to determine acute and sub-chronic lung toxicity profiles resulting from exposures to e-cigarette aerosols in mice. Findings may inform future regulatory activities related to e-cigarettes.

Implied Modified Risk Statements as Predictors of Flavored Little Cigar and Cigarillo Use

Several brands of flavored little cigar and cigarillos (LCCs) come in packages that use potential modified risk descriptors (e.g., “additive-free”). The goal of this study is to examine how young adults’ receptivity to flavored LCC product packaging features (e.g., text, colors, images, pack size) and price influences their smoking behavior. Study aims are: (1) to assess the impact of flavored LCC packaging descriptors in risk perceptions and future LCC smoking behaviors among young adult LCC current users and non-users; and (2) to assess the influence of flavored LCC package features on young adults’ preferences for LCCs. Researchers will conduct a 12- and 24- month online survey (1,120 young adults ages 18-34 in each wave) to examine transitions in risk perceptions and subsequent LCC smoking behavior that occur due to receptivity to flavored LCC packaging descriptions. Also, six focus groups (with 6-8 participants per group), stratified by race/ethnicity and smoking status, will be conducted after each survey wave to understand what factors influenced transitions in receptivity, risk perceptions, and LCC smoking profiles. Next, researchers will conduct a discrete choice experiment to assess the impact of packaging features such as text, color, images, and pack size, as well as price, on the product preferences on 250 ever and 250 never LCC users ages 18-34. Findings may inform future regulatory activities related to LCC packaging.

Investigating the Cardiovascular Toxicity of Exposure to Electronic Hookah Smoking

Electronic hookah (e-hookah) bowls, which contain flavored e-liquid that is heated electrically but inhaled through traditional waterpipes, are increasing in popularity in the United States. The goals of this study are to compare the effects of traditional hookah smoking with e-hookah inhalation on human vascular and endothelial function, and to examine the role of inflammation and oxidative stress in hookah-related cardiovascular disease development. Study aims are: (1) to determine the acute effects of e-hookah bowl inhalation on endothelial function; (2) to determine the acute effects of e-hookah bowl inhalation on arterial stiffness; and (3) to determine the acute effects of e-hookah bowl inhalation on biomarkers of oxidative stress and inflammation. Researchers will conduct cross-over studies in 18 young adult hookah smokers (ages 21-39). Findings will provide new information about the effects of e-hookah use on human health and may inform regulatory activities related to e-hookah.

Effects of E-Cigarette Exposure During Pregnancy on Offspring Lung Function and Disease: Characterization of Pulmonary, Intergenerational, and Epigenetic Effects

Nearly all the effects of maternal smoking during pregnancy on fetal lung development are caused by nicotine crossing the placenta to interact with nicotinic receptors in the developing lung. The goal of this study is to use a mouse model to describe the effects of perinatal e-cigarette exposure on offspring pulmonary function and disease. Study aims are: (1) to characterize the direct effect of maternal in-utero e-cigarette exposure on first-generation offspring pulmonary function, respiratory disease and epigenetic changes; (2) to characterize the intergenerational effect of grand-maternal in-utero e-cigarette exposure on second-generation offspring pulmonary function, respiratory disease and epigenetic changes; and (3) to characterize the additive, multigenerational effect of both grand-maternal and maternal in-utero e-cigarette exposure on offspring pulmonary function, respiratory disease and epigenetic changes. Researchers will expose pregnant mice to filtered air, e-cigarettes without nicotine, and e-cigarettes with nicotine from gestation day 1 to postnatal day 7 and will analyze effects on lungs at age 8 weeks; in addition, they will analyze the effects of in-utero exposures on asthma susceptibility based on sensitivity to house dust mite antigen. Researchers will conduct similar analyses on the second-generation mice to determine intergenerational effects. Findings will provide new information about the effects of e-cigarette use by pregnant women.

Airway Protein Modifications caused by New and Emerging Tobacco Products as Markers of Exposure and Potential Health Risks

The use of new and emerging tobacco products (NETPs) such as hookah and e-cigarettes is increasing, particularly by the younger population in the US. The goal of this study is to examine airway protein modifications that result from NETP use. Study aims are: (1) to identify NETP-induced protein modifications in vitro of smoke/vapor-exposed human bronchial epithelial cell (HBEC) surfaces (airway epithelial cells for analysis are routinely received and subsequently maintained by the institution); and (2) to establish protein modifications as markers of NETP use and effects in vivo by conducting mass spectrometry analysis of tobacco product user sputum samples (previously collected from healthy cigarette, e-cigarette and hookah users ages 18-50). Findings will provide new information about the airway toxicity effects of tobacco product use.

CRoFT TCORS: WNY Center for Research on Flavored Tobacco Products (CRoFT)

Many tobacco flavoring ingredients are labeled Generally Recognized as Safe (GRAS) as they are intended for ingestion; however, they have not been evaluated for inhalation toxicity. More data can provide understanding regarding how consumers perceive and use flavored tobacco products and whether these have implications for health. The goal of the Western New York (WNY) Center for Research on Flavored Tobacco Products (CRoFT) is to develop a novel framework and approaches for assessing the impact of tobacco product flavors and flavorings on consumer behavior, exposures, and health. Four projects will provide useful information about the toxicological, health, and behavioral implications of flavors and flavoring chemicals. Project 1 will apply state-of-the art methods to assess the chronic toxicity of specific flavorings used in tobacco products using chemical reactivity, in vitro models, and in vivo research studies. Project 2 will apply consumer sensory and behavioral laboratory approaches to examine the behavioral impacts of flavors, including sensory thresholds for single and combined flavorings, and the impact of flavoring concentration on use patterns (puffing topography, inhalation). Project 3 will apply longitudinal cohort and product-switching designs to examine the chronic respiratory health effects of flavorings in tobacco products among current users. Project 4 will apply qualitative, quantitative, and experimental approaches to examine the effects of information on flavor choice and flavored product use.

CRoFT TCORS Project 1: In Vitro and In Vivo Assessment of Flavorant Toxicity

Commonly-marketed flavors in emerging tobacco products such as e-cigarettes, cigarillos, and waterpipe tobacco include tobacco, mint/menthol, fruits/candy, coffee/tea, chocolate, berries, crème/butter, clove/cinnamon, and alcoholic beverages. Underlying these flavors are chemical flavorings, some of which have known respiratory toxicity (e.g., diacetyl, cinnamaldehyde). Comparative toxicity data would be useful to clarify the health effects of these tobacco products. The goal of this Center for Research on Flavored Tobacco Products (CRoFT) project is to determine and compare the effects of various flavorings in e-cigarettes, cigarillos, and waterpipe tobacco on toxicological and immune-inflammatory responses. Study aims are: (1) to determine comparative in vitro toxicity of selected tobacco product flavorings using (a) the aerosol exposure system for cell-free reactive oxygen species reactivity, and (b) exposure to human lung epithelial cells via air-liquid interface and 3D culture; (2) to determine comparative oxidative, DNA damage and immune-inflammatory responses to tobacco product flavorings in a mouse model to determine the link between flavoring toxicity and adverse respiratory health outcomes; and (3) to identify comparative biomarkers in response to tobacco product flavorings. Assessment of toxicity within the same class of flavorings across different types of tobacco products will allow a toxicity/hazard ranking and information related to flavoring-specific adverse health outcomes.

CRoFT TCORS Project 2: Human Thresholds for Characterizing Flavors and Impact on Behavior

Flavors are common in electronic nicotine delivery systems (ENDS) and are often named as a primary reason for their use. The goal of this Center for Research on Flavored Tobacco Products (CRoFT) study is to evaluate whether flavors might have “indirect” toxicity: that is, regardless of whether flavorings show biological evidence of toxicity, they may increase harm by other means, such as increasing appeal, decreasing risk perceptions, or masking harshness or irritation that might lead users to discontinue use. Study aims are: (1) to develop expert (trained per industry best practices) and consumer (untrained) sensory panels to identify and assess characterizing flavors in e-liquids; and (2) to examine the effects of flavorings on use topography, subjective effects of vaping, and sensory experience among current ENDS users. For Aim 1, researchers will compare the ability of trained and untrained individuals to identify and characterize flavors, determine threshold detection levels for individual and mixed flavors, and identify the dominant flavor of mixtures; four panels (expert user, expert nonuser, consumer user, consumer nonuser) of 35 individuals each (ages 18-55) will be convened. For Aim 2, researchers will examine whether flavor concentration affects use topography (puff volume, puff duration, inhalation volume, breathhold duration), subjective effects, and detection of “dry puff” under high power conditions in 120 daily e-cigarette users (ages 18-49). Findings may inform future regulatory activities related to flavors.

CRoFT TCORS Project 3: Respiratory Health Effects of Flavors

More information about the respiratory health hazards of the flavorings used in tobacco products would be useful. The goal of this Center for Research on Flavored Tobacco Products (CRoFT) project is to characterize the respiratory health effects — including inflammation, biomarkers of exposure, and clinical markers with relevance to disease endpoints — attributable to the use of flavored tobacco products. Two studies will evaluate daily ENDS users as they switch among various flavors. Study aims are: (1) to assess changes in respiratory symptoms and biomarker levels in ENDS users during spontaneous switching between flavors (Study 1); (2) to evaluate respiratory symptoms in ENDS users switching from flavors of potentially high toxicity to flavors of potentially low toxicity (Study 2); and (3) to characterize ENDS users’ preferences, selection, patterns of use and switching between various flavors (Studies 1&2). In Study 1, researchers will establish a cohort of 176 ENDS users (ages 18-54) to assess changes in respiratory symptoms during spontaneous switching among flavors over one year. In Study 2, researchers will conduct a randomized, parallel-group open-label trial to evaluate respiratory symptoms in 216 ENDS users (ages 18-54) switching from higher-toxicity to lower-toxicity flavors (as identified by Project 1). Endpoints will include clinically relevant biomarkers of inflammation and oxidative stress, changes in respiratory function, subjective respiratory symptoms and side-effects, and expression of immune and inflammatory response genes in nasal epithelial cells. Results may inform future regulatory activities related to flavors.

CRoFT TCORS Project 4: Evaluating Effects of Packaging and Market Availability of Flavored Tobacco Products on Consumer Perception and Behavior

Flavored tobacco products influence appeal, use, and perceptions of reduced harm. This project will investigate how descriptor terms such as “natural”, “cherry gummy bear”, “Neapolitan ice cream”, and “chocolate milk shake” and pictures illustrating those terms influence perceptions of appeal, harm, and intention to use, among both current and susceptible non-users of electronic nicotine delivery systems (ENDS). The goal of this Center for Research on Flavored Tobacco Products (CRoFT) project is to evaluate perceptions of flavored tobacco products and relevant messages as conveyed by package design characteristics (i.e., colors, design, descriptor terms), as well as the potential impact on demand and behavior, for cigarettes, cigarillos/little cigars, and ENDS. Study aims are: (1) to evaluate how to communicate messages about flavors and potential harms associated with specific flavors to consumers of combustible tobacco products and ENDS; and (2) to evaluate the potential effects on tobacco use behavior of flavored tobacco products with varied risk messaging and changes in market availability (e.g., restricted range of flavors, changes in descriptors). Researchers will conduct three studies in adults (ages 18 and older) to achieve these aims. In Study 1, researchers will conduct eight focus groups with 100 participants and 20 in-depth one-on-one interviews to examine beliefs and behaviors related to flavored e-cigarette use. In Study 2, researchers will conduct a mall-intercept survey experiment with 192 e-cigarette users and susceptible non-users to obtain reactions to e-cigarettes/e-liquids with fictitious packaging/brand names. In Study 3, researchers will conduct an experimental auction in which 384 participants bid on five unflavored and flavored products (four types of e-cigarettes and one pack of cigarettes or little cigars) to examine the influence of changes in market availability of flavored tobacco products on willingness to pay. Findings may inform future regulatory activities related to flavors.

USC TCORS: Tobacco Regulatory Science Investigating the Intersections of Products with Diverse Populations

The University of Southern California Tobacco Center of Regulatory Science (USC-TCORS) will conduct research on the use and health effects of specific e-cigarette products across populations. Researchers will study e-cigarette product characteristics and marketing approaches hypothesized to increase tobacco product attraction, use, and addiction in youth and young adult non-smokers and have little impact on tobacco product use in older smokers. These characteristics and marketing approaches include: (a) non-tobacco flavorings; (b) constituents and devices that produce large vapor clouds and the user experience; (c) modifiable devices; (d) device designs not resembling cigarettes; (e) cartoons in packaging and advertising; and (f) candy flavors or other youth-oriented marketing themes. The TCORS will include four projects. Project 1 will characterize publicly available social media postings of e-cigarette product characteristics and marketing themes and will study links with tobacco product use behavior in youth and young adults. Project 2 will involve vape shop customer interviews to assess the impact different e-cigarette regulation scenarios on tobacco product use. Project 3 will study associations of e-cigarette product characteristics and marketing exposures with tobacco product use and dependence across 10 years (ages 14-25). Project 4 will involve laboratory tests of the impact of e-cigarette product characteristics and marketing exposure manipulations on product appeal, abuse liability, and other outcomes.

USC TCORS Project 1: Effects of Social Media Marketing and Messages on Tobacco Transitions

More information about e-cigarette product diversity portrayed on social media and how social media exposure impacts tobacco product use would be useful. The goal of this project is to examine how social media portrays e-cigarette product diversity and how this portrayal may affect tobacco product transitions. Study aims are: (1) to analyze continuously collected social media posts that include e-cigarette and other tobacco product-related keywords to determine trends in product marketing and conversations about e-cigarette products and their diverse product characteristics; and (2) to determine whether participation (e.g., posting, liking, sharing) in e-cigarette-related social media, especially posts that contain youth-oriented themes, is associated with tobacco product susceptibility and use among youth and young adults. To address Aim 1, researchers will collect, code, and analyze messages posted on popular social media sites using existing tobacco-related keywords and identifying new keywords; they will identify types of tobacco messages (e.g., youth-oriented messages, health-oriented messages aimed at current smokers) and the characteristics of messages about e-cigarettes that generate the most user engagement and dissemination. To address Aim 2, researchers will analyze publicly-available and accessible e-cigarette-related social media postings generated by participants in a cohort of adolescents and young adults (ages 14-25) in Southern California to determine links between posting and transitions across six stages of tobacco use (non-susceptible never-user, susceptible never-user, single product experimenter, poly-tobacco experimenter, single-product regular user, poly-tobacco regular user). Findings will provide new information about the links between exposure to products and marketing via social media and tobacco product use and transitions.

USC TCORS Project 2: Influence of Tobacco Product Characteristics and Marketing on Diverse Populations of Vape Shop Customers

Vape shops, which specialize in selling a variety of e-cigarette products, are a key channel of exposure to these products. The goal of this project is to examine how different segments of the vape shop customer population would likely react to hypothetical e-cigarette regulations. The project will contrast three groups of vape shop customers — e-cigarette-only users (who never smoked cigarettes extensively); switchers (who quit smoking and now only use e-cigarettes); and dual users (who currently use both e-cigarettes and cigarettes) —regarding perceived appeal and anticipated purchase/use of e-cigarettes and combustible products currently and after hypothetical regulatory changes. Study aims are: (1) to test the hypothesis that hypothetical regulations related to sweet flavors, e-liquid propylene glycol/vegetable glycerin ratios, and ability to calibrate a device will be associated with lower e-cigarette appeal and lower anticipated future purchase/use in e-cigarette-only users (vs. switchers and dual users); (2) to test hypothetical marketing practices that may be associated with lower e-cigarette appeal and lower anticipated future purchase/use in e-cigarette-only users (vs. switchers and dual users); (3) to test the hypothesis that these hypothetical product regulations and marketing practices will be associated with lower e-cigarette appeal and lower anticipated purchase/use among young adults (age 21-29) vs. middle/older adults (30+); and (4) to examine the above associations as a function of (a) current product(s) used, (b) race/ethnicity, (c) gender, (d) socioeconomic status, and (e) shop location. Researchers will conduct interviews with customers (ages 21 and older) exiting vape shops in a racially/ethnically diverse set of neighborhoods. Findings may inform future regulatory activities related to e-cigarettes.

USC TCORS Project 3: Product Characteristics, Marketing, and E-cigarette and Cigarette Use Across Adolescence and Young Adults

E-cigarette product diversity (i.e., product characteristics and associated marketing strategies) can affect product appeal and use, especially among adolescents and young adults. The goal of this project is to test hypothesized e-cigarette product characteristics and marketing strategies that may attract never-smokers and put them at risk for tobacco product use but do not affect the likelihood that young smokers will adopt and switch to e-cigarettes. Examples of product features that may disproportionately attract never smokers (vs. smokers) include sweet flavors (vs. tobacco or other flavors), devices and e-liquid compositions used to generate large aerosol clouds for “vape tricks” (vs. devices that look and feel like cigarettes), and youth-oriented marketing strategies for e-liquid naming (such as “Kustard Killer”) and packaging with cartoon images. Study aims are: (1) to evaluate the associations of: (a) product characteristics and marketing exposure with e-cigarette interest, (b) e-cigarette interest with subsequent initiation, and (c) marketing exposure with subsequent initiation; (2) to evaluate the association of (a) e-cigarette initiation with cigarette initiation and progression, or discontinuation of tobacco product use, and (b) e-cigarette product characteristics and marketing exposure with dual use, nicotine dependence, or discontinuation of tobacco product use; and (3) to evaluate whether associations of product characteristics and marketing with outcomes observed in Aims 1 and 2 differ between baseline never-smokers and smokers. Researchers will survey participants in a cohort of adolescents and young adults (ages 14-25) in Southern California. Findings may inform future regulatory activities related to e-cigarettes.

USC TCORS Project 4: Human Laboratory Research to Inform Precision Regulation of E-cigarettes Across Populations

E-cigarettes may adversely impact the health of some populations (e.g., young never-smokers), but also may reduce health risk in others (e.g., middle-aged/older smokers who completely switch to e-cigarettes). The goal of this project is to identify dimensions of e-cigarette product diversity that put young adult never-smokers at risk of using e-cigarettes, yet do not deter middle/older adult smokers from adopting and potentially switching to e-cigarettes. Study aims are: (1) to determine which dimensions of e-cigarette product diversity differentially affect product appeal in never-smoking young adult e-cigarette users and middle-aged/older adult smokers with an interest in, but no significant experience with, e-cigarettes; (2) to determine which dimensions of e-cigarette product diversity differentially affect abuse liability in never-smoking young adult e-cigarette users and ability to resist smoking in middle-aged/older adult smokers with an interest in, but no significant experience with, e-cigarettes; and (3) to examine sex differences in the effects of product diversity on appeal, abuse liability, and ability to resist smoking by testing sex and product dimension interactions. In two studies, subjects will self-administer e-cigarette products varied according to three dimensions: flavor (e.g., sweet vs. menthol vs. tobacco); propylene glycol/vegetable glycerin ratio (e.g., 20:80 vs. 40:60 vs. 60:40 vs. 80:20); and packaging design (e-liquid characterizing flavor label [e.g., “peach”] vs. youth-oriented non-characterizing flavor [e.g., “gummy heaven”] vs. non-characterizing flavor + cartoon). The Aim 1 study will test product exposure effects on subjective ratings of appeal (e.g., liking, desire to use again). The Aim 2 study will test product exposure effects on choice to use (vs. earn money) the previously-exposed e-cigarette product (an abuse liability test; never-smoking young adults only), or own brand cigarettes (test of ability to resist smoking; middle-age/older adult smokers only). Findings may inform future regulatory activities related to e-cigarettes.

UPenn/Rutgers TCORS: Examining the Effects of Advertising, Packaging and Labeling on Perceptions, Use and Exposure of Combustible Tobacco Products

Tobacco advertisements are an important marketing vehicle that allows companies to prominently and creatively feature brand imagery and benefit claims, including those that might suggest modified risk. In addition, tobacco packaging uniquely provides repeated opportunities to express brand image and implicitly convey brand attractiveness, quality and health appeals to consumers every time the product is used. The goal of the University of Pennsylvania – Rutgers University TCORS is to accumulate a comprehensive and rigorous body of knowledge on the effects of tobacco communication, including advertising, marketing, packaging and labeling, on regulatory-relevant outcomes of risk perceptions, use, behavior and exposure for combustible tobacco products, given their disproportional burden on public health. The UPenn & Rutgers TCORS includes four projects. Project 1 will study the effects of cigarette package color on smoking behavior, exposure and risk perception when using low nicotine content cigarettes. Project 2 will examine the effects of advertising and correctives for reduced harm tobacco products. Project 3 will study the influence of cigarillo packaging and labeling on young adults. Project 4 will examine products that have descriptors that may imply modified risk.

UPenn/Rutgers TCORS Project 1: The Effects of Cigarette Package Color on Smoking Behavior, Exposure and Risk Perception when using Low Nicotine Content Cigarettes

Cigarettes with reduced nicotine content decrease dependence and toxicant exposure, suggesting potential public health benefits of mandating a low nicotine product standard. These findings, however, come primarily from studies using investigational low nicotine content (LNC) cigarettes in basic packaging with no accompanying marketing campaign. Thus, there is no data currently available to clarify the impact of product marketing. The goal of this project seeks to evaluate the effects of LNC cigarette packaging on two primary outcomes: smoking behavior and biological toxicant exposure. Study aims are: (1) to examine the effect of cigarette packaging on smoking behavior during LNC use; and (2) to examine the effect of cigarette packaging on biological exposure during LNC use. Researchers will recruit 500 currently daily cigarette smokers (ages 21-65) to a 35-day randomized controlled trial; after a five-day period of smoking their own cigarettes, participants will be randomized to continue smoking their own brand (control group) or to smoke investigational LNC cigarettes in one of four types of packaging (red/blue/gray/plain) for 30 days. Outcomes will include smoking behavior (daily cigarette consumption, total puff volume), biological exposure (total nicotine equivalents, NNAL, carbon monoxide), subjective ratings (taste, smoking satisfaction, perceived nicotine strength, harshness), and risk and harm perceptions. Findings will provide important information about low nicotine content cigarettes in the context of cigarette packaging.

UPenn/Rutgers TCORS Project 2: The Effects of Advertising and Correctives for Reduced Harm Tobacco Products

Misperceptions of the risks of potential modified risk tobacco products (MRTPs) can be exacerbated by product marketing. The goal of this project is to develop scientifically rigorous protocols to establish the magnitude and strength of inaccurate beliefs created by advertising and marketing practices for potential MRTPs in target audiences. The studies proposed in this project focus on advertising claims about combustible MRTPs and identifying the associated beliefs – both harms and benefits – in the minds of both likely users (smokers) and former smokers. Study aims are: (1) to understand the effects of advertising about potential MRTPs on product beliefs; (2) to assess the impact of potential MRTP ad content on beliefs about and attitudes and intentions toward MRTPs and examine whether false beliefs mediate the link between ad claims and attitudes/intentions; and (3) to design simple correctives to modify inaccurate inferences about potential MRTPs and assess their ability to change inaccurate (but not accurate) beliefs, redirect attention to corrective information, and affect MRTP use behavior. Eight studies will address these three aims. To address Aim 1, researchers will monitor past and current requests to FDA for MRTP approval of combustible tobacco products (Study 1), track beliefs about MRTPs derived from online comments by members of the public (Study 2), conduct a descriptive pilot study with 1000 current and 1000 former smokers (ages 18 and older) to derive a set of targeted beliefs (Studies 3 and 4), and conduct a study to determine whether ad content can encourage beliefs in one direction or another (Study 5). To address Aim 2, researchers will evaluate beliefs of 1500 participants (ages 18 and older) using standardized assessment tools to determine whether beliefs mediate between advertising claims and attitudes and use intentions (Study 6). To address Aim 3, researchers will conduct two studies in current daily smokers (ages 21-60); an eye tracking study (Study 7) as well as behavioral tests of MRTP use in the presence and absence of corrective statements (Study 8). Findings may inform future regulatory activities related to potential MRTP advertising.

UPenn/Rutgers TCORS Project 3: Influence of Cigarillo Packaging and Labeling on Young Adults

The use of cigarillos is growing among young adults. Therefore, more information about the influence of cigarillo packaging and labeling on young adults would be useful. The goal of this project is to understand how cigar and cigarillo packaging and labeling may both facilitate and dissuade cigar among young adults (ages 18-24). Using a series of complementary mixed methods studies (i.e., online exposure experiments, observational secondary data analyses, smoking lab study), researchers will study the effects of exposure to cigar/cigarillo packaging with varying warning labels (text and pictorial) and descriptors (flavors and potentially modified-risk claims) on perceptions, use intentions, and use. Study aims are: (1) to test the effect of different cigarillo packaging features (descriptors, colors, presence of current warning labels) on perceptions and use intentions among 2400 young adult past-year cigarillo smokers using a between-subjects online experiment; (2) to compare the effect of different text and pictorial warnings on cigarillo perceptions and use intentions among 1,800 young adults using an online experiment; and (3) to evaluate exposure to cigar warnings (and associations with cigar harm perceptions and use) over time through an analysis of Population Assessment of Tobacco and Health (PATH) survey data. In addition, in an exploratory smoking experiment, 100 young adult past 30-day cigarillo smokers will smoke non-flavored cigarillos placed in packaging with flavor descriptors, allowing researchers independently examine the potential impact of packaging and descriptors on cigar ratings. Study findings may inform future regulatory activities related to cigar and cigarillo flavoring, packaging descriptors, packaging, and pictorial warnings.

UPenn/Rutgers TCORS Project 4: Examining Product Descriptors in Natural American Spirit Cigarette Marketing

Extensive research has confirmed that cigarettes marketed as “light,” “low tar,” and “mild” were misperceived as having lower risks. In recognition of this, the 2009 Tobacco Control Act (TCA) banned the use of these descriptors in one of its earliest regulatory actions but did not address other misleading terms that studies have shown also suggest reduced harm for products utilizing them. One of these products is Natural American Spirit, a heavily-advertised and top-selling premium cigarette brand popular among young adults that promoted itself using the terms “additive free,” “natural,” and “organic.” The goal of this project is to provide additional scientific evidence on product descriptors that may imply a health claim, such as the terms “natural,” “additive-free,” and “organic.” Study aims are: (1) to understand consumer perceptions of brand name, descriptors (e.g., “organic”, “Tobacco Ingredients: Tobacco and Water”), and imagery advertising by conducting 12 focus groups each with 6-8 young adult (ages 18-24) smokers and nonsmokers; (2) to assess the effect of potentially misleading descriptors in print advertising on cigarette risk perceptions and use intentions among 2400 young adult (ages 18-24) smokers and non-smokers using a between-subjects online experiment; and (3) to examine population differences in tobacco perceptions, use intentions, and use between products that may imply a modified risk or health claim and other brand smokers, comparing them over time through analysis of Population Assessment of Tobacco and Health (PATH) study data. A secondary aim will be to monitor claims and images used in cigarette advertising with a longitudinal content analysis of print and direct mail advertising. Findings will advance the evidence base on the impact of misleading terms implying reduced risk.

U of M TCORS: Center for the Assessment of the Public Health Impact of Tobacco Regulations

The University of Michigan Center for the Assessment of the Public Health Impact of Tobacco Regulations aims to provide evidence-based and expert-informed modeling of the behavioral and public health impacts of tobacco regulations. The Center will have three projects based on detailed analysis of historical tobacco use patterns in the U.S. and will use four established tobacco simulation models. Project 1 will involve comparative modeling analyses of the impact of tobacco regulations and policies on smoking and e-cigarette use and related long-term health outcomes, including heart, pulmonary disease and maternal and child health. Project 2 will extend two well-established models to examine the possible consequences of regulating nicotine in combusted tobacco products. Project 3 will model tobacco-related health disparities associated with single- and multi-product tobacco use and will investigate how potential policy options may impact tobacco use and tobacco-related health disparities.

U of M TCORS Project 1: Comparative Modeling of the Impact of E-cigarettes use on Smoking and Long-Term Health Outcomes

The goal of this project is to use four established tobacco control simulation models to examine the impact of different possible FDA regulatory actions on future trends in cigarette and e-cigarette use and associated health outcomes. Study aims are: (1) to characterize differences in cigarette and e-cigarette use patterns and to monitor changes in use patterns over time; (2) to extend well-established simulation models so that they consider mortality from specific health outcomes, including lung cancer, chronic obstructive pulmonary disease (COPD), cardiovascular disease, and maternal and child health outcomes; (3) to project mortality from lung cancer, COPD, cardiovascular disease, and low birth weight births under current cigarette and e-cigarette use patterns (status quo); (4) to estimate the impact of past and potential new tobacco control policies on patterns of cigarette and e-cigarette use; and (5) to model the impact of past and potential new policies on all-cause mortality and health outcomes associated with cigarettes and e-cigarettes. Researchers will use a generalized decision analysis framework and statistical approaches to develop initial prevalence rates for the models, a range of plausible future status quo transitions by age and gender for initiation and cessation of cigarettes and e-cigarettes, and a range of plausible switching rates between cigarettes and e-cigarettes. Using literature reviews and expert elicitation panels, researchers will develop relative risk estimates for specific health outcomes, and then will project tobacco-related mortality due to cardiovascular disease, COPD, and adverse maternal and child health outcomes. Researchers will extend the models to project how specific potential regulatory activities (e.g., health warnings on cigarette packages; public education campaign) individually and in combination will likely impact cigarette and e-cigarette use rates and associated health outcomes over a 50-year future period. The models may be extended to consider other nicotine delivery products, including cigars, smokeless tobacco and heat-not-burn products. Results will provide evidence-based, expert-informed estimates of tobacco use prevalence, health outcomes, and policy impacts.

U of M TCORS Project 2: Modeling the Impact of Nicotine Regulation on Smoking and Smoking-Related Mortality

The Food and Drug Administration (FDA) has the authority to regulate nicotine levels on all tobacco products. The focus has been primarily on lowering nicotine to minimally or non-addictive levels in cigarettes. While lowering nicotine levels in cigarettes might lead to declining smoking rates, such policies could generate unintended consequences that would undermine their effectiveness. The goal of this project is to examine how nicotine regulation may impact public health, including possible unintended consequences from compensation behaviors and the emergence of a black market. Study aims are: (1) to modify two existing U.S. population-based dynamic smoking prevalence and mortality models to account for the effects of policies that reduce nicotine to non-addictive levels in all combusted tobacco products; (2) to model the number of new smokers, smoking prevalence trajectory, and smoking-related mortality in the U.S. population from 2018-2100 in the absence of nicotine regulation; and (3) to conduct policy simulation exercises on the impact of nicotine regulations on smoking prevalence and associated mortality. Researchers will focus on the impact of potential nicotine policy-related changes on smoking prevalence and overall mortality; however, other health outcomes may be incorporated as they become available from Project 1 of this TCORS. While the focus of this project will be on nicotine reduction, the models will be flexible enough to examine the effect of other FDA regulations to alter cigarette content, such as limits on specific toxic ingredients, as well as the influence of other tobacco control policies. Results may inform potential regulatory activities related to nicotine.

U of M TCORS Project 3: Modeling the Impact of Tobacco Control Policies on Polytobacco Use and Associated Health Disparities

More information about how the evolving tobacco marketplace will shape the patterns of tobacco use, their subsequent long-term health effects, and potential disparities by socioeconomic status (SES) and race/ethnicity would be useful. Simulation modeling can predict future health outcomes and provide insights into how different policies and regulations may affect disparities in tobacco use and downstream health outcomes. The goal of this project is to estimate tobacco-related health disparities associated with tobacco use and to investigate the impact of specific tobacco control policy options on these disparities. Study aims are: (1) to estimate current disparities in single- and multi-product tobacco use by SES and race/ethnicity and monitor changes in consumption patterns over time; (2) to estimate the impact of past tobacco control policies on patterns of tobacco and nicotine product use by SES and race/ethnicity; (3) to estimate tobacco-related health disparities in all-cause mortality, cardiovascular mortality, and other health outcomes associated with single- and multi-product tobacco use and the role of past policies in influencing these outcomes; and (4) to model the impact of potential new policies on tobacco use and on tobacco-related health disparities associated with single- and multi-product tobacco use. To address Aim 1, researchers will use five datasets to characterize single- and multi-product tobacco use, including initiation, cessation, relapse, and switching, across demographic groups. To address Aim 2, researchers will use literature reviews, data analyses, and expert panels to determine a range of plausible values for the effect of different potential policies on initiation, cessation, relapse, and single- and multi-product use for key sociodemographic subgroups. Using results from Aims 1 and 2, Aims 3 and 4 will expand simulation models to project the consequences of tobacco use on tobacco-related health disparities. Results will indicate which potential tobacco control policies may be most effective in reducing tobacco-related health disparities due to tobacco use over time.

The Effects of E-liquid Nicotine Concentration on the Abuse Liability of ENDS in Current Users

Studies reveal that large differences (>100%) in nicotine content affect the abuse liability of e-liquids, but more information demonstrating how smaller differences in nicotine affect abuse liability of electronic nicotine delivery systems (ENDS) would be useful. The goal of this study is to determine how modest differences (e.g., ±20%) in e-liquid nicotine concentration affect the abuse liability of ENDS. Following an initial laboratory phase where study e-liquids/aerosol and participants’ own brands of e-liquids will be chemically characterized, 30 adult current ENDS users will participate in five ad libitum vaping sessions where they will use five e-liquids, each containing a different nicotine concentration. Measures of abuse liability will include pharmacokinetic and pharmacodynamic data, biomarkers of nicotine exposure, puff topography, and subjective measures of craving, withdrawal, liking, and reinforcement. Findings may inform regulatory standards for tobacco products.

E-Cigarette Effects on Markers of Cardiovascular and Pulmonary Disease Risk

The goal of this study is to relate the acute and long-term use of e-cigarettes and conventional cigarettes to cardiovascular and pulmonary disease biomarkers. Researchers will enroll four different “use-groups” of adults ages 18 and older (n=440): exclusive e-cigarette users (n=110), exclusive cigarette smokers (n=110), dual product users (who both smoke and vape; n=110), and never smokers (n=110). These groups reflect the primary decisions that individuals can make regarding their future tobacco use: to continue to smoke cigarettes, to switch to e-cigarettes, to use both cigarettes and e-cigarettes, or not to use these products. Product use will be related to biomarkers that accurately and reproducibly reflect mechanisms, injury, and future risks related to cardiovascular or pulmonary disease. Primary cardiovascular biomarkers measured will include brachial artery flow-mediated dilation (a measure of endothelial function) and carotid intima-media thickness, a measure of subclinical arterial injury and atherosclerosis. Primary pulmonary disease biomarkers will be measures of lung volumes and flow rates (predicted FEV1, FVC, FEV1/FVC) obtained by spirometry. Researchers will also conduct treadmill exercise stress testing (to assess aerobic fitness), perform electrocardiography (to measure heart rate and its variability), and measure blood pressure, lipids, HgbA1c, inflammation/oxidation markers (leukocyte count, C-reactive protein, urinary F2 isoprostanes) and exhaled nitric oxide. Study findings will yield new data regarding product use, subclinical arterial injury, atherosclerosis burden, arterial and pulmonary function, cardiac and aerobic fitness, cardiac autonomic dysregulation, systemic and pulmonary inflammation, and oxidative stress, as well as other key outcomes.

Integrated Risk Assessment and Molecular Characterization of Pulmonary Response to E-cigarette Exposure

E-cigarette aerosol is a complex mixture of e-liquid components (propylene glycol, vegetable glycerol, nicotine, water, and flavoring additives) and other constituents (such as aldehydes, metals, nanoparticles, and some unknown compounds) produced during e-cigarette heating. The goals of this study are to evaluate the oxidative stress and inflammation resulting from e-cigarette aerosol, identify aerosol constituents’ distinct “signatures” of early oxidative/nitrative damage in cells and tissue, and use these findings to evaluate the relative hazards of constituents. Researchers will use the Research Grade E-cigarette (REC) device developed at Battelle to generate and characterize aerosol from individual e-liquid components with and without the use of a heated coil. Study aims are: (1) to characterize e-cigarette aerosol generated at moderate and high heating temperatures; (2) to characterize pulmonary response to e-cigarette aerosol constituents in mice; and (3) to predict airway deposition and site-specific tissue dose and translation to humans using computational fluid dynamic-physiologically-based pharmacokinetic (CFD/PBPK) models. Study findings will provide new information about the oxidative and inflammatory effects of e-cigarette use.

Exploring Cardiovascular and Other Health Associations of Electronic Cigarette Use in US Persons of Hispanic Heritage: The Hispanic Community Health Study / Study of Latinos (HCHS/SOL)

Information on the effects of electronic nicotine delivery system (ENDS) use on cardiovascular disease (CVD) and other health risks in minority populations would be useful. The goal of this study is to examine associations between ENDS use and CVD and other health risks in the Hispanic/Latino population. Researchers will analyze existing data from a large community-based sample of more than 12,000 individuals of Hispanic/Latino origin (ages 18-74 at baseline) who participated in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) at both baseline (2008-2011) and follow-up (2015-2017). Study aims are: (1) to determine the prevalence of ENDS use and assess demographic, socio-economic, and cultural factors associated with use; (2) to study associations of ENDS use with levels of CVD risk factors, other health measures, assessments of subclinical atherosclerosis, and markers of inflammation, including heart rate, blood pressure, high-density lipoproteins (HDL), low-density lipoproteins (LDL), triglycerides, fasting glucose, body mass index, and white blood count, taking into account history and current use of tobacco products; (3) to study changes between baseline and follow-up in associations of ENDS use with CVD risk factors, other health measures, and markers of inflammation, taking into account history and current use of tobacco products; and (4) to obtain new data to examine ENDS use as it relates to motivations, dose, flavors, and duration by mailing a questionnaire to users who participated in the HCHS/SOL follow-up. Findings will provide new information about the cardiovascular impact of ENDS use in the Hispanic/Latino population.

Evaluation Support: Rapid Assessments of State and Local Tobacco Control Policies

This project involves maintaining and evaluating an ongoing systematic approach for identifying relevant state and local tobacco control policies for potential evaluation. This approach includes conducting environmental scans, performing evaluability assessments, conducting pilot evaluations, conducting data analyses for evaluation purposes, and reporting key findings to FDA-CTP on an ongoing basis.

The Role of ENDS Use in Changing Rates of Escalation and Quitting of Cigarette Smoking in Those Under Age 35 Years in US Population

Electronic nicotine delivery systems (ENDS) have the potential to reduce the proportion of young adults who are addicted to cigarette smoking, either by reducing escalation to daily cigarette smoking or increasing cessation before age 35. The goal of this study is to determine whether ENDS use changes the pattern of escalation and early cessation among those younger than age 35 using data from the first four waves of the Population Assessment of Tobacco and Health (PATH) Study. Study aims are: (1) to examine the contribution of early use of ENDS and other tobacco products in differentiating early cigarette smoking escalators from those who do not escalate before age 20; (2) to examine the contribution of ENDS use to late escalation of tobacco use; and (3) to identify whether ENDS use is associated with long-term discontinuation of cigarette smoking in people under age 35. Researchers will conduct separate analyses for early escalators, late escalators, and quitters before age 35, and will use various analytical methods including propensity score matching, marginal structural models, and targeted maximum likelihood estimation techniques. Findings may provide new information related to the potential long-term impact of ENDS use.

The Impact of Design Characteristics on the Modification Potential of Electronic Nicotine Delivery Systems

Different designs of electronic nicotine delivery systems (ENDS) make them more or less likely to be modified by users, which may impact the public health effect of their use. The goal of this study is to evaluate who is most likely to modify ENDS, how and why consumers modify ENDS, how much modification is occurring, and what design characteristics lead to modification. Study aims are: (1) to identify ways that consumers modify ENDS; (2) to determine the extent to which ENDS modification occurs in the U.S. population; and (3) to evaluate the ENDS product characteristics that lead to modification and what motivates modification. To address Aim 1, researchers will conduct interviews with 12 ENDS enthusiasts, analyze social media websites, conduct three focus groups with 20 young adult ENDS users (ages 18-29) and three focus groups with 20 adult ends users (ages 30+); and individual interviews with 20 adolescent ENDS users (ages 12-17). To address Aim 2, researchers will conduct a population-level quantitative survey of current ENDS users (750 adults, 750 young adults, and 750 adolescents) to estimate the prevalence of modification activities and differences by user profile (e.g., dual ENDS/cigarette users vs. exclusive ENDS users). To address Aim 3, researchers will use the data from the quantitative survey to evaluate the association of ENDS characteristics with different types of product modifications. Findings will provide new information about ENDS modification activities and may inform regulatory activities related to ENDS design.

Impact of Nicotine Reduction on Adolescent Cigarette Use, Alternative Tobacco Use, and Harm from Tobacco

Youth who use multiple tobacco products differ from youth who solely smoke cigarettes in ways that may affect their responses to a nicotine reduction regulatory policy, which would mandate a reduction of nicotine in all commercially available cigarettes. The goal of this study is to examine the effects of very low nicotine content (VLNC) cigarettes on multiple tobacco product use and toxicant exposure in youth. Following a one-week baseline period, researchers will randomize adolescent cigarette smokers (ages 15-19, n=120) who report past-month alternative tobacco product use to a four-week trial during which they will switch from their usual brand cigarettes to either VLNC or normal-nicotine content (15.8 mg/g nicotine) study cigarettes. This study will use laboratory-based assessments to investigate the effects of cigarette nicotine reduction on: cigarette and multiple tobacco product use; the harms associated with tobacco use, including nicotine and toxicant exposure; and effects on respiratory symptoms, perceived health risk, and nicotine dependence. Using real-time smartphone-based assessments in the natural environment, researchers will also examine the role of nicotine withdrawal and craving in understanding how cigarette nicotine reduction may affect other tobacco use. Findings will provide new information about the effects of VLNC cigarettes on real-world tobacco use and indices of tobacco-related harm in adolescents.

How Consumers Use Flavors to Make Inferences about Electronic Nicotine Delivery System (ENDS) Product Qualities and Intentions to Use (Phase 2)

This project (Phase 2) will test how different features used to advertise electronic nicotine delivery system (ENDS) flavors are associated with product appeal and intentions to use the product. Specifically, researchers will examine three features identified previously (Phase 1): the use of flavor-related imagery (e.g., picture of a cherry), the use of flavor name modifiers (e.g., Cherry Crush), and the use of flavor descriptors (e.g., “cool”, “fresh”). In Phase 2, researchers will collect data and conduct six analyses, each with four outcomes: (a) product appeal, (b) curiosity about the product, (c) interest in using the product, and (d) increased positive product perceptions (e.g., likeliness to switch from cigarettes, good taste, health effects). Analyses 1 and 2 will investigate whether absence of a flavor-representing image is associated with decreased outcomes compared to an identical ad with a flavor-representing image, and whether presence of the image is associated with increased outcomes compared to an identical ad without any flavor feature. Analyses 3 and 4 will investigate whether absence of a flavor name modifier is associated with decreased outcomes compared to an identical ad with the modifier, and whether presence of the modifier is associated with increased outcomes compared to an identical ad without any flavor features. Finally, analyses 5 and 6 will investigate whether absence of a flavor descriptor is associated with decreased outcomes compared to an identical ad with the descriptor, and whether presence of a descriptor is associated with increased outcomes compared to an identical ad without any flavor features. Secondary analyses will explore sub-group differences among flavors and brands, as well as effects on broader product perceptions, including relative risk and harm. Findings may inform future regulatory activities related to ENDS flavors and marketing.

Evaluation of Canada’s Menthol Ban

Menthol cigarettes comprise a substantial portion of the American cigarette market, with prevalence estimates reaching about 25%. A US ban on menthol cigarettes would likely elicit changes in the behavior of menthol cigarette smokers and the tobacco industry. On January 1, 2017, the Province of Ontario implemented one of the first bans on menthol products worldwide; a full Canadian ban followed on October 1, 2017. The goal of this study is to conduct a long-term assessment of the menthol ban in Ontario to provide information about its potential impact. Study aims are: (1) to understand tobacco use behavior changes by pre-ban menthol smokers; (2) to characterize industry and sales changes subsequent to the ban; and (3) to explore how menthol cigarette smokers transition from menthol cigarettes to either smoking cessation/reduction or replacement tobacco products. To address these aims, researchers will follow up with of a cohort of 1,738 smokers aged 16 and older surveyed pre-ban to examine smoking behaviors and attitudes two years post-ban. Researchers will also conduct an analysis of administrative tobacco product sales data reported to Health Canada to examine changes in sales and changes in characteristics of products sold post-pan in Ontario and nationally. Finally, researchers will conduct a concept mapping study to supplement the self-reported data and administrative data with an in-depth understanding of user behavior. Findings will reveal menthol smoker and tobacco industry responses to a real-world menthol-flavored tobacco ban, which may inform future regulation and associated public education messaging.

Assessing Physiological, Neural, and Self-Reported Response to Tobacco Education Messages

This project uses neuroimaging, physiological, and self-report measures to assess responses to FDA tobacco education messages from “The Fresh Empire”, “The Real Cost” and “This Free Life” campaigns. To align with FDA campaign target audiences, the project will recruit 100 adolescents (ages 12-17, stratified by race/ethnicity), 50 young adults (ages 18-24, stratified by LGBT status), and 50 adult smokers (ages 25-54, stratified by past-year quit attempt). Physiological measures will assess indicators of arousal (such as heart rate variability) and affective response (such as facial muscle activity). Functional near-infrared spectroscopy (fNIRS), a brain monitoring technique, will measure activation of different brain areas to assess message processing and acceptance. Eye tracking methods will be used to assess attention to messages and message features. Self-report measures will assess message efficacy (e.g., perceived effectiveness, recall, comprehension, agreement with the message main point) and indicators of persuasive processes (e.g., identification with characters, transportation into the message, emotional response, counterarguing). Outcome measures will include changes from baseline in knowledge, attitudes and behavioral intent. Findings will enhance the understanding of effective tobacco education messaging tactics and may inform future tobacco education campaigns.

Measurement of Metal Ions and HPHCs in Electronic Nicotine Delivery Systems (ENDS) and Their Physio-pathological Impact on Cells of the Oral Cavity and Upper Respiratory Tract

This project will use the electronic nicotine delivery systems (ENDS) aerosolization machine previously developed by the research team to expose normal human cells to complex ENDS aerosol mixtures and determine the physiological and pathological effects from exposure. Study aims are: (1) to determine the effects of ENDS aerosol on cells of the oral cavity and upper respiratory tract, and (2) to identify the constituents of e-liquids, hardware and aerosol to which ENDS users are exposed. In this study, five pre-filled ENDS and two cartomizers and their associated e-liquid formulations will be aerosolized and effects on cells will be assessed (via proteomics and in vitro cell biology assays of specific biological pathways by immunoblotting, cytokine quantitation and metallomics) against appropriate controls. Researchers will also analyze ENDS hardware, e-liquids (including color and ingredients), and the constituents of the complex aerosol for each ENDS category evaluated. All data collected will be compiled into a database that may help to inform the regulatory decision-making process. Project findings may inform future regulatory activities related to ENDS.

Addiction and Behavior Related to Menthol Cigarette Substitutes

Several products in the tobacco marketplace – including mentholated pipe tobacco (for roll-your-own cigarettes, mRYO), menthol filtered little cigars (mFLC), and non-menthol cigarettes (nmC) — could serve as substitutes for menthol cigarettes. The goal of this study is to examine the abuse liability and substitutability of these potential menthol cigarette alternatives. Specific aims are: (1) to assess the abuse liability of menthol cigarette alternatives; (2) to assess the substitutability of menthol cigarette alternatives; and (3) to evaluate which product characteristics and perceived effects influence greater substitution. Eighty current menthol cigarette smokers (40 smokers ages 18-24 and 40 smokers ages 25+) will complete a three-phase study. In Phase 1, participants will complete four smoking sessions, smoking a different product in each session to examine each product’s abuse liability, demand, and topography. Products will include participants’ usual brand menthol cigarette (UBMC) and three commercially-available alternatives, including mFLC, an mRYO product, and nmC. In Phase 2, to assess uptake, changes in subjective effects, and use over time, participants will select their preferred study product from Phase 1 and completely substitute the product for their UBMC for one week. Participants will complete ecological momentary assessments (EMA) during this period to more accurately assess substitution and perceived effects in real time. In Phase 3, participants will complete a final laboratory visit to assess the substitutability of their preferred product from Phases 1 and 2, under simulated menthol cigarette ban conditions using a progressive ratio task. In all phases, multiple domains of abuse liability will be assessed, including product administration, product liking/craving, and withdrawal suppression. Findings will provide new information regarding the substitutability of potential menthol cigarette substitutes in adult smokers and may inform future regulatory activities related to menthol cigarettes.

UVM TCORS: University of Vermont Tobacco Center of Regulatory Science

Building upon research in the previous TCORS, the University of Vermont TCORS will conduct research projects on the impact of low nicotine content cigarette use in four vulnerable populations: socioeconomically disadvantaged women of reproductive age (Project 1), individuals with comorbid opioid use disorders (Project 2), individuals with comorbid affective disorders (Project 3), and pregnant women (Project 4). Each of these populations is at increased risk for tobacco use, dependence, and/or tobacco-related adverse health outcomes. Despite their increased risk, these populations are often excluded from tobacco regulatory studies, leaving a significant knowledge gap. The overall goal of the UVM TCORS is to provide sound scientific evidence on the impacts of tobacco products in vulnerable populations. The projects will examine the extent to which the availability and appeal of alternative non-combusted sources of nicotine (i.e., e-cigarettes) may moderate the impact of reduced nicotine standards on reducing cigarette smoking. That topic will be investigated in each of the primary vulnerable populations of interest, using common study protocols to the extent possible, as well as protocols that facilitate comparisons with studies in healthier populations as noted above.

UVM TCORS Project 1: Low Nicotine Content Cigarettes in Vulnerable Populations: Economically Disadvantaged Women (Non-Pregnant)

Despite marked reductions in cigarette smoking in the general population, smoking rates among economically disadvantaged women have increased. Smoking among women of reproductive age is a concern because in addition to the usual health risks, they face additional risks should they become pregnant. Research indicates that economically disadvantaged women respond to low nicotine content cigarettes (VLNCCs) with reductions in smoking rates, cigarette demand, dependence severity, and other measures of addiction. The goal of this project is to evaluate whether increased availability and appeal of an alternative non-combusted nicotine source (e-cigarettes) will enhance the effectiveness of a reduced-nicotine standard for cigarettes in socioeconomically disadvantaged female smokers of reproductive age. Study aims are: (1) to compare the effects of normal nicotine content cigarettes (NNCCs) alone, VLNCCs alone, VLNCCs + tobacco-flavored e-cigarettes, and VLNCCs + preferred-flavor e-cigarettes on total number of cigarettes per day; (2) to compare the effects of the four study conditions on cigarette demand, smoke exposure (breath carbon monoxide), and tobacco carcinogen biomarkers (NNAL, PAH metabolites); (3) to explore the effects of the four study conditions on cerebral blood flow, other measures of brain function and structure, and airway inflammation; and (4) to explore the effects of the four study conditions on abstinence-induced cigarette demand, craving, and withdrawal. In this study, 212 disadvantaged female smokers (ages 18-44) will be randomized to 16 weeks of: (1) NNCCs alone (the control condition); (2) VLNCCs alone; (3) VLNCCs + nicotinized tobacco-flavored e-cigarettes; or (4) VLNCCs + nicotinized preferred-flavor e-cigarettes. Participants will complete two in-person assessments (involving baseline health and smoking assessments, a variety of questionnaires, biomarker assessments, cognitive functioning tests, and functional MRI) and use an interactive voice response system to report daily product use and nicotine withdrawal symptoms. After 16 weeks of use, participants will undergo an abstinence assessment in which researchers will examine the effects of the study conditions on participants’ ability to abstain from cigarettes and their responses to abstinence. Findings may inform regulatory activities related to reduced-nicotine cigarettes.

UVM TCORS Project 3: Low Nicotine Content Cigarettes in Vulnerable Populations: Affective Disorders

Affective disorders (ADs; mood and anxiety disorders) are the most common mental health conditions in the US. Over 40% of people with ADs are current smokers, and they experience disproportionately high rates of tobacco-related disease and death. Research indicates that smokers with ADs respond to very low nicotine content cigarettes (VLNCCs) with reductions in cigarette demand and other measures of addiction. The goal of this project is to evaluate whether increased availability and appeal of an alternative non-combusted nicotine source (e-cigarettes) will enhance the effectiveness of a reduced-nicotine standard for cigarettes in smokers with ADs. Study aims are: (1) to compare the effects of normal nicotine content cigarettes (NNCCs) alone, VLNCCs alone, VLNCCs + tobacco-flavored e-cigarettes, and VLNCCs + preferred-flavor e-cigarettes on total number of cigarettes per day; (2) to compare the effects of the four study conditions on cigarette demand, psychiatric symptoms, smoke exposure (breath carbon monoxide), and tobacco carcinogen biomarkers (NNAL, PAH metabolites); (3) to explore the effects of the four study conditions on cerebral blood flow, other measures of brain function and structure, and airway inflammation; and (4) to explore the effects of the four study conditions on abstinence-induced cigarette demand, craving, and withdrawal. In this study, 236 adults with ADs (ages 18-70) will be randomized to 16 weeks of exposure to (1) normal nicotine content cigarettes alone, which will serve as the control condition, (2) VLNC cigarettes alone, (3) VLNCs + tobacco-flavored nicotinized e-cigarettes, or (4) VLNCs + nicotinized e-cigarette with preferred flavoring. Participants will complete two in-person assessments (involving baseline health and smoking assessments, a variety of questionnaires, biomarker assessments, cognitive functioning tests, and functional MRI) and use an interactive voice response system to report daily product use and nicotine withdrawal symptoms. After 16 weeks of use, participants will undergo an abstinence assessment in which researchers will examine the effects of the study conditions on participants’ ability to abstain from cigarettes and their responses to abstinence. Findings may inform regulatory activities related to reduced-nicotine cigarettes.

UVM TCORS Project 4: Low Nicotine Content Cigarettes in Vulnerable Populations: Pregnant Women

Approximately 11% of U.S. women (~17 million women) are smokers when they become pregnant, with prevalence as high as 40% among socioeconomically disadvantaged women. Smoking during pregnancy can cause catastrophic pregnancy complications and adverse effects on fetal development that a growing body of evidence suggests can compromise health throughout the lifespan. Researchers are currently conducting a multi-site study examining the acute effects of very low nicotine content cigarettes (VLNCCs) on the addiction potential of smoking in pregnant women; the goal of this project is to further this line of research by examining extended exposure. Study aims are: (1) to compare extended exposure to either usual brand cigarettes or VLNCCs on number of cigarettes smoked per day; (2) to quantify the effects of extended exposure to VLNCCs on measures of biomarkers of exposure (total cotinine, NNAL, PAH) and sonographic assessments of fetal growth and body composition; and (3) to compare the effects of VLNCCs on abstinence-induced cigarette demand, craving, and withdrawal. It should be noted that a recommendation to all women screened for this study will be that they should quit, consistent with ethical guidelines about smoking during pregnancy. All potential participants will be asked at screening about their intentions to quit smoking during pregnancy. Those with intentions to quit in the next 12 weeks will be referred to our ongoing studies on smoking cessation in pregnant women. Those who do not will be randomized to smoke either usual brand cigarettes or VLNCCs for 12 weeks. Ninety participants (ages 18-44) will complete two in-person baseline assessments (involving baseline health and smoking assessments, a variety of questionnaires, biomarker assessments, and fetal measurements) and will be seen weekly throughout the study. Findings may inform regulatory activities related to reduced-nicotine cigarettes.

A-TRAC TCORS: American Heart Association Tobacco Center for Regulatory Science (A-TRAC) 2.0

The overall goal of the American Heart Association (AHA) Tobacco Regulation Center (A-TRAC) is to provide scientific data relevant to the cardiovascular effects of tobacco products by evaluating the cardiovascular effects of tobacco products and their constituents. A-TRAC will support three projects. Project 1 will assess the toxicity of tobacco products and their constituents in in vitro assays and animal models. Project 2 will evaluate short- and long-term cardiovascular health effects of tobacco products. Project 3 will assess the cardiovascular disease risk associated with the use of non-cigarette tobacco products in multiple large NIH-supported cardiovascular cohorts. Research supported by the A-TRAC will develop new understanding of the cardiovascular effects of current, new and emerging tobacco products; and build and deploy capacity and expertise to respond to new developments.

A-TRAC TCORS Project 1: Cardiovascular Toxicity of Tobacco Products

Cardiovascular disease (CVD), including coronary heart disease and stroke, is the leading causes of death and disability associated with tobacco use. However, more information would be useful regarding specific tobacco product constituents that affect cardiovascular toxicity. The goal of this American Heart Association Tobacco Center for Regulatory Science (A-TRAC) project is to test the hypothesis that cardiovascular injury due to tobacco product use could be attributed mostly to volatile organic compounds (VOCs; e.g., formaldehyde, acetaldehyde, acrolein, benzene, xylene) generated in a variety of tobacco products. Study aims are: (1) to quantify the cardiovascular toxicity of tobacco product-derived VOCs in human cells in vitro; (2) to assess short-term and chronic toxicity of tobacco products (i.e., combustible cigarettes, smokeless tobacco, electronic nicotine delivery systems, electronic and conventional hookah) using a mouse model; and, (3) to identify individual VOCs that mediate the cardiovascular toxicity of tobacco products. To test this hypothesis, researchers will define the contribution of VOCs to the cardiovascular toxicity of tobacco products using sensitive and informative in vitro assays and well-controlled animal exposures. Findings will provide new information related to the cardiovascular toxicity of tobacco products and their constituents to inform future regulatory activities.

A-TRAC TCORS Project 2: Cardiovascular Injury Due to Tobacco Use

The goal of this American Heart Association Tobacco Center for Regulatory Science (A-TRAC) project is to assess and evaluate the cardiovascular effects of non-cigarette tobacco products and to determine whether cardiovascular injury due to tobacco product use is mediated, in part, by exposure to volatile organic chemicals (VOCs) present in or generated by tobacco products. To describe the contribution of VOCs to cardiovascular injury and dysfunction induced by tobacco products, researchers will evaluate the short- and long-term cardiovascular health and disease risk in 555 adult (ages 18-45) users of cigarettes, e-cigarettes, and cigarillos. Study aims are: (1) to identify cardiovascular harm associated with the use of e-cigarettes and cigarillos; (2) to examine the acute cardiovascular effects of e-cigarettes and cigarillos; and (3) to identify cardiovascular disease risk associated with chronic use of e-cigarettes and cigarillos. To accomplish these aims, researchers will examine baseline differences in biomarkers of endothelial injury, inflammation and thrombosis and indices of vascular function and cardiac excitability in e-cigarette and cigarillo users and compare results with cigarette smokers and individuals who do not use tobacco products. To examine long-term effects of tobacco products, researchers will identify progressive changes in cardiovascular disease risk due to continued use of tobacco products over two to six years. Findings will provide new information related to the cardiovascular toxicity of tobacco products and may inform future regulatory activities.

A-TRAC TCORS Project 3: Cardiovascular Effects of Tobacco Products in Community-based Cohorts

Although overwhelming evidence supports the association between cigarette smoking and cardiovascular disease, the cardiovascular effects of other tobacco products such as cigars, pipes, smokeless tobacco, and e-cigarettes remain unclear. The goal of this American Heart Association Tobacco Center for Regulatory Science (A-TRAC) project is to assess the cardiovascular health impact of these less frequently used tobacco products. Study aims are: (1) to use the Cross Cohort Collaboration (CCC) dataset to harmonize tobacco data across 18 cohort studies and to create the largest cardiovascular study of cigar, pipe, and smokeless tobacco users yet undertaken (among 200,000 total cohort participants, there are 65,000 former smokers, 24,000 current smokers, 2,900 cigar users, 3,300 pipe users, and 1,900 smokeless tobacco users); (2) to use the CCC dataset to examine whether the use of cigars, pipes, and smokeless tobacco is associated with volatile organic compound (VOC) exposure, biomarkers of subclinical inflammation, vascular injury, and cardiovascular events; and (3) to develop e-cigarette use data from existing cardiovascular cohort studies to undertake first-of-its-kind study of the cardiovascular health effects of e-cigarettes in a large geographically dispersed, community-based sample (~1500-2000 ever e-cigarette users, ~600 current e-cigarette users). Aggregate data from these aims will be used to test the hypothesis that non-cigarette tobacco product use is associated with significant cardiovascular injury, which is attributable, in part, to VOCs generated by or present in these products. Findings will provide new information related to the cardiovascular impact of tobacco product use and may inform future regulatory activities.

UCSF TCORS: Integrated Health, Behavioral and Economic Research on Current and Emerging Tobacco Products

The goal of this TCORS is to examine health effects, behavior, and impact related to current and emerging tobacco products, including e-cigarettes, smokeless tobacco, and new “heated tobacco products (HTPs). Specific aims are: (1) to evaluate the short-term health effects, including respiratory and cardiovascular effects, of e-cigarettes, HTPs, and other tobacco products and how specific tobacco product characteristics influence health effects and behavior; (2) to further add to the science base to inform product standards and marketing regulations for these tobacco products, integrating the health and behavioral dimensions of tobacco use with economic models, with particular emphasis on specific product characteristics and short-term effects; and (3) to build the tobacco regulatory science research community through mentoring, developmental grants, and other support. The TCORS will accomplish these aims through five projects; topics are as follows: (1) the impact of different e-cigarette characteristics on acute lung injury; (2) the short-term cardiovascular effects of e-cigarettes, including the influence of device power and e-liquid pH, and how e-cigarettes compare with HTPs; (3) the cardiovascular health effects of emerging HTPs; (4) the influences of product characteristics on perceptions, behaviors, and biologic exposures in rural adolescents; and (5) the impact of changing tobacco product use on healthcare costs for general and vulnerable populations. Project findings may provide information that may inform future regulatory activities.

UCSF TCORS Project 1: Impact of Different E-Cigarette Characteristics on Acute Lung Injury

Variation in e-cigarette characteristics may have a significant impact on pulmonary health. Changes in e-cigarette device and liquid characteristics may influence acute pulmonary effects, both under healthy conditions and in the setting of acute respiratory infection and/or inflammation. This project proposes a comprehensive assessment of the impact of e-cigarette characteristics on acute lung injury, combining data from cell culture, mouse models, and human subjects. Study aims are: (1) to test how different device characteristics (applied power and metal coil components) impact the acute pulmonary effects of e-cigarettes; and (2) to test how different e-liquid characteristics (nicotine concentration and flavorings) impact the acute pulmonary effects of e-cigarettes. Both aims begin with an evaluation of the impact of varying e-cigarette characteristics on susceptibility to viral or bacterial lung injury in cell culture and mouse models. This evaluation will be conducted with and without infectious and inflammatory stimuli, including viral (influenza) and bacterial (pneumococcal) infection. The e-cigarette characteristics that appear to be most important in these models will then be tested in a human model of lung inflammation, in which 60 healthy adult (age >21) e-cigarette users and dual cigarette/e-cigarette users inhale endotoxin, followed by bronchoscopy with bronchoalveolar lavage. Findings will yield new information regarding how specific e-cigarette device and e-liquid characteristics impact their potential to cause acute lung injury and may inform future regulatory activities.

UCSF TCORS Project 2: Short-Term Cardiovascular Effects of E-Cigarettes: Influence of Device Power and E-Liquid pH and How E-Cigarettes Compare with Heat-Not-Burn Products

This project will provide more information about how specific aspects of e-cigarettes influence their overall health effects, including short-term cardiovascular effects. The goal of this project is to evaluate the impact of e-cigarette power on cardiovascular effects; the influence of e-liquid pH on rate of systemic nicotine absorption, nicotine-induced sympathetic nervous system stimulation, and heart rate increase (a risk factor for cardiovascular disease); and the health effects of heated tobacco products (HTPs), which heat tobacco without combustion. Study aims are: (1) to determine the impact of e-cigarette power on nicotine pharmacology, systemic exposure to toxic volatile organic compounds (VOCs), and short-term cardiovascular effects; (2) to determine the impact of changes in e-liquid pH on nicotine pharmacokinetics, cardiovascular, and subjective effects of e-cigarettes; and (3) to compare differences in nicotine pharmacology, systemic exposure to toxic VOCs, and short-term cardiovascular effects of e-cigarettes and an HTP (iQOS). These aims will be achieved through three studies, one study for each aim. Each study will be conducted on an inpatient research ward and will include 21 healthy users (age >21) of e-cigarettes and/or an HTP. Studies 1 and 2 will test different electrical power and e-liquid pH levels, respectively. Study 3 will be a within-subject comparison of toxicant exposure and the cardiovascular effects of e-cigarettes compared to iQOS. Study endpoints will include markers of cardiovascular disease risk, such as heart rate and blood pressure changes, hormonal release, biomarkers of endothelial function, platelet activation, inflammation, and oxidative stress. Findings will contribute to knowledge of the influence of e-cigarette characteristics on short-term cardiovascular effects and may inform future regulatory activities.

UCSF TCORS Project 3: Cardiovascular Health Effects of Emerging Heat-Not-Burn Tobacco Products

Heated tobacco products (HTPs), which heat a mixture of tobacco and other compounds to temperatures below those at which combustion occurs, deliver an inhalable aerosol containing nicotine and other chemicals. Despite harm reduction claims, the health effects of HTPs are poorly understood. The goal of this project is to evaluate the cardiovascular effects of an HTP (iQOS), including effects on cardiac and peripheral vascular function and cardiac tissue preservation after acute myocardial infarction, relative to tobacco smoke and e-cigarette aerosol. Study aims are: (1) to understand the chemical properties of HTP aerosol and chemical changes during its generation; (2) to evaluate and understand cardiovascular health effects of both acute and repeated exposure to HTP aerosol in rats; and (3) to determine whether acute and chronic exposure to HTP aerosol prior to acute myocardial infarction increases the extent of the resulting cardiac tissue death. To satisfy aim 1, researchers will perform chemical analyses of HTP aerosol and compare results to the chemical composition of unused HTP tobacco and to residual HTP tobacco after use. To satisfy aim 2, researchers will collect functional measurements in rats following HTP aerosol exposure and will evaluate the effects of single acute exposures and repeated exposures over 14 days. To satisfy aim 3, researchers will induce myocardial infarction in rats after a single brief exposure or multiple exposures to HTP aerosol or cigarette smoke and measure the extent of cardiac tissue damage. Results may inform future regulatory activities related to HTPs.

UCSF TCORS Project 4: Current and Emerging Tobacco Products in a Rural Context: Influences of Product Characteristics on Perceptions, Behaviors, and Biologic Exposures

In recent decades, smokeless tobacco (ST) use has shifted from an older to a younger demographic, along with increasing industry marketing and expanding diversity in ST product characteristics. New ST products include different types, brands, flavors, and levels of nicotine and cancer-causing nitrosamines. More information about how different characteristics of ST products and other tobacco products contribute to youth perceptions, initiation, established use, poly-use, and exposure to nicotine and carcinogens would be useful. Study aims are: (1) to identify the impact of ST and other tobacco product characteristics, including packaging, characterizing flavors, and product design, on rural adolescents’ perceived harm, acceptability, and appeal of current and emerging smokeless, combustible, and alternative tobacco products; (2) to characterize tobacco use behaviors over time (e.g., initiation, cessation, changes in intensity, product switching, and poly-use) and how family and social factors and specific product characteristics predict transitions in behavior; and (3) to evaluate the impact of tobacco product use on rural adolescents’ exposure to nicotine and tobacco-specific nitrosamines. This study will include 1500 adolescents (aged 14-16) attending seven rural high schools in California, followed for five survey waves over 24 months. Qualitative studies (focus groups and one-on-one interviews) with adolescents and their parents/guardians will be conducted to provide information about how product characteristics and socio-contextual factors influence perceptions and behavioral decisions regarding tobacco products. Collected biomarkers (saliva specimens to measure cotinine levels; urine specimens to measure levels of the nitrosamines NNN and NNAL) will reveal how exposure to nicotine and nitrosamines varies with differences in product use and use patterns. Study findings will improve understanding of how different characteristics of ST and emerging tobacco products impact behavior and health effects in rural adolescents.

UCSF TCORS Project 5: Impact of Changing Tobacco Product Use on Healthcare Costs for General and Vulnerable Populations

Many factors contribute to tobacco-attributable healthcare costs, including changing tobacco product use patterns, sociodemographic characteristics, health status, and socioeconomic status (SES). The goal of this project is to develop economic models that analyze the impact of new patterns of tobacco product use on healthcare costs for different populations, including vulnerable populations. Study aims are: (1) to develop microeconomic models to estimate the healthcare costs attributable to e-cigarette use; (2) to estimate healthcare costs attributable to cigarette smoking and e-cigarette use for vulnerable populations (people with low SES, rural populations, people with medical co-morbidities, and youth); (3) to develop microeconomic models to estimate the healthcare costs attributable to the most common combinations of tobacco product use (i.e., dual use of cigarettes and e-cigarettes; dual use of cigarettes and cigars; and poly-use of cigarettes, e-cigarettes, and other tobacco products); and (4) to analyze potential scenarios to determine the likely impact of regulatory changes on healthcare costs. Tobacco-attributable healthcare costs will be estimated using econometric models and an approach in which costs among product users are compared with costs among people assumed to be never tobacco users or sole cigarette smokers (depending on the relevant comparison group). The healthcare cost estimates from this project will be useful metrics for measuring the impact of tobacco use on public health, allowing a comparison of the relative magnitude of health effects of different tobacco products on specific populations.

VCU TCORS: Center for the Study of Tobacco Products

Methods exist for assessing a regulation’s effects once it is in place, but few models predict impact beforehand. The VCU Center for the Study of Tobacco Projects (CSTP) will explore a model that may allow the prediction of regulatory impact. The model assesses how a potential regulation might change product toxicity, user behavior, and addiction/abuse liability. To verify the model, the CSTP will also examine the extent to which its predictions about potential regulatory effects describe actual population-level outcomes. This TCORS includes four projects. Projects 1, 2 and 3 will test hypotheses and generate predictions regarding the impact of three potential e-cigarette regulations (i.e., limit e-cigarette liquid nicotine concentration, constrain rate of e-cigarette nicotine emission or “flux”, reduce e-cigarette liquid flavor availability); specifically, researchers will assess how each potential regulation might influence product toxicity (Project 1), user behavior (Project 2), and addiction/abuse liability (Project 3). Project 4 will evaluate the predictions generated by Projects 1,2, and 3 at the population level by surveying current exclusive e-cigarette users and e-cigarette/cigarette dual users (ages 18 and older) every three months for four years. VCU CSTP’s goal is to provide tools to guide regulation development so that, by the time a regulation goes into effect, validated methods have tested it, refined it, and generated data showing that its health-promoting effects are maximized and unintended consequences are minimized. The model and associated tools may be used to shape, refine, and predict the effects of many potential regulatory actions in the future.

VCU TCORS Project 1: Using Toxicity Testing Data to Test Hypotheses about Advanced-Generation ECIGs and Generate Population-level Predictions Regarding Potential Regulatory Action

The goal of this project is to examine how e-cigarette toxicant emissions are influenced by several potential regulatory actions. This project’s three study aims will use established aerosol research and analytical chemistry methods to evaluate how three potential regulatory actions — (1) limits on e-cigarette nicotine concentration, (2) constraints on e-cigarette nicotine flux, and (3) reduction in e-cigarette flavor availability – might influence e-cigarette emissions. For Aim 1, researchers will use our previously published mathematical model that predicts e-cigarette nicotine flux to explore conditions under which e-cigarette liquids containing <20 mg/ml nicotine might exceed tobacco cigarette nicotine yield, and then measure actual nicotine and non-nicotine toxicant yields for these conditions. For Aim 2, researchers will manipulate nicotine flux and then examine how flux manipulation influences the toxicity of the resulting e-cigarette aerosols. For Aim 3, researchers will explore the non-nicotine toxicant emissions produced by do-it-yourself e-cigarette liquids. This project will provide new data regarding the role of nicotine concentration, flux, and liquid flavor availability on e-cigarette toxicity, while informing predictions regarding the consequences of potential regulatory action.

VCU TCORS Project 2: Using User Behavior Data Collected in the Clinical Lab to Test Hypotheses about Advanced-generation ECIGs and Generate Population-level Predictions Regarding Potential Regulatory Action

E-cigarette nicotine delivery, user subjective response, and user behavior measures (such as puff topography) can be assessed using rigorously-controlled, well-established clinical laboratory methods. The goal of this project is to use these established clinical laboratory methods to examine the extent to which e-cigarette nicotine delivery, e-cigarette liquid consumption, subjective response, and puff topography are influenced by manipulations of e-cigarette liquid nicotine concentration and device power, nicotine flux, and flavor availability. Study aims are: (1) to manipulate e-cigarette liquid nicotine concentration and device power to evaluate how nicotine delivery, abstinence suppression, and e-cigarette liquid consumption change as nicotine concentration is lowered, and whether these changes are offset by higher power; (2) to manipulate nicotine flux to determine whether nicotine delivery and abstinence suppression are related directly to flux; and (3) to manipulate e-cigarette liquid flavors to determine whether nicotine delivery, abstinence suppression, and e-cigarette liquid consumption vary by flavor for e-cigarette users and for smokers. The three aims correspond to three independent studies, each involving exclusive e-cigarette users and non-e-cigarette-using cigarette smokers (ages 18-55). This project will assess the nicotine delivery and subjective response profile of e-cigarettes, will generate new data regarding the effects of advanced-generation e-cigarettes on user behavior, and will contribute to population-level predictions.

VCU TCORS Project 3: Using Abuse Liability Data to Test Hypotheses about Advanced-Generation ECIGs and Generate Population-level Predictions Regarding Potential Regulatory Action

Behavioral economic tasks reveal how much people are willing to pay for nicotine delivery, how hard they will work to earn nicotine delivery, and how price sensitive their product choices are. This project will use standard abuse liability assessments to examine the extent to which response to behavioral economic tasks is influenced by three potential regulatory actions: limits on e-cigarette liquid nicotine concentration, constraints on nicotine flux, and reduction in flavor availability. Study aims are: (1) to manipulate e-cigarette liquid nicotine concentration and device power to evaluate whether abuse liability is altered as nicotine concentration is lowered, and whether this effect is offset by higher power; (2) to manipulate nicotine flux to determine the extent to which willingness to pay/work and price sensitivity are directly related to nicotine flux; and (3) to manipulate e-cigarette liquid flavors to determine whether predictors of abuse liability vary with flavor differently for e-cigarette exclusive users than for dual users. The three aims correspond to three independent studies, each involving exclusive e-cigarette users and dual e-cigarette and tobacco cigarette users (ages 18-55). Findings will provide new data regarding e-cigarette abuse liability in two populations that will likely be impacted by regulatory actions, and will generate predictions regarding the consequences of three potential regulatory actions.

VCU TCORS Project 4: Using a Prospective Cohort Survey to Test Population-level Predictions Generated by Projects 1-3

Examining how potential regulatory actions influence product toxicity, user behavior, and product abuse liability in controlled settings can help generate predictions regarding regulatory consequences at the population level. However, the extent to which these predictions reflect real-world behavior should be tested. The goal of this project is to survey current exclusive e-cigarette users and e-cigarette/cigarette dual users (ages 18 and older) to test population-level predictions that arise from the studies conducted in Projects 1-3 of the VCU TCORS. Specifically, the study will assess the population-level effects of three potential regulatory actions: limits on e-cigarette liquid nicotine concentration, constraints on e-cigarette nicotine flux, and reduction in e-cigarette flavor availability. Study aims are: (1) to assess relationships among nicotine concentration, amount of e-cigarette liquid consumed, and device power; (2) to assess relationships among nicotine flux and e-cigarette use, dependence and transitions; and (3) to examine associations between availability of e-cigarette liquid flavors and e-cigarette use behavior. After an initial survey, follow-up survey waves will occur regularly for four years. Survey questions will be designed to monitor e-cigarette use behaviors and e-cigarette liquid and device characteristics. Measures will include frequency of use; current device type, wattage, voltage, and resistance; presence of nicotine; nicotine concentration, propylene glycol/vegetable glycerin ratio; flavor preference; frequency of do-it-yourself e-cigarette liquid mixing; method, location and price of purchase; length of e-cigarette/tobacco cigarette cessation (if any); abstinence effects; tobacco cravings; dependence; and respiratory symptoms. A subgroup of participants will undergo puff topography measurement so that nicotine flux can be calculated.

Animal Models to Inform FDA Tobacco Regulation: Assessing the Relative Abuse Liability of Different Classes of Tobacco Products

Although nicotine is the main addictive chemical in tobacco, other chemicals may also contribute to tobacco addiction. The goal is to understand whether non-nicotine constituents unique to cigarette smoke contribute to differences in abuse liability between conventional combusted cigarettes and non-combusted products like e-cigarettes, smokeless tobacco, and nicotine replacement therapy (NRT), using rat models of abuse liability including self-administration. Researchers will measure levels of non-nicotine constituents (e.g., monoamine oxidase [MAO] inhibitors, volatile organic compounds [VOCs]) and identify the specific constituents that may be responsible for observed differences in abuse liability. Study aims are: (1) to compare demand for cigarette smoke extract to nicotine dose-equivalent concentrations of smokeless tobacco extract, e-cigarette extract, and nicotine alone when each is available in isolation or under choice procedures to determine relative reinforcing efficacy and substitutability of the extracts and nicotine alone; (2) to compare reinforcement-enhancing and aversive effects between extracts and nicotine alone; and (3) to evaluate the reinforcement-enhancing and aversive effects of isolated MAO inhibitors and VOCs when administered alone or in combination with nicotine. Findings will provide information about how chemicals other than nicotine contribute to tobacco addiction and may inform regulatory activities.

Dissolution of Smokeless Tobacco Products

The purpose of this study is to characterize the nicotine release profiles of smokeless tobacco products available in the US to investigate the effects of tobacco blend changes, formulation changes, pH changes, and differences in physical parameters on nicotine release and to create a baseline for product comparison. Study aims are: (1) to develop and validate a method for nicotine quantification using high performance liquid chromatography/ultra-performance liquid chromatography-mass spectrometry (HPLC/UPLC-MS) to measure nicotine in the selected dissolution medium; and (2) to develop and validate dissolution methods (USP 4 and Chewing gum tester) for different categories of smokeless tobacco products and to analyze their nicotine release profiles. Findings will provide new information about the effects that different tobacco blends, pouch materials, pH buffers and buffering capacity, and other additives have on nicotine release from smokeless products.

Yale TCORS Project 1: Effects of Sweet and Coolant Flavors on Nicotine Choice, Consumption and Seeking

The proportion of users of sweet-flavored and mentholated tobacco products has increased dramatically, especially among adolescents, raising concerns that flavors may facilitate tobacco product initiation and promote nicotine addiction. An additional concern is the recent introduction of synthetic cooling agents that may have effects similar to menthol. Children and adolescents are conditioned, through prior experience, to associate sweet and cooling flavors (fruit, candy, mints, etc.) with high sweetener content (sugar or artificial sweeteners). However, the role of flavors in the initiation of tobacco product use is difficult to study in humans, especially in adolescents and never-users. The goal of this project is to use adolescent and adult rodent models of inhaled and smokeless tobacco product use, and of oral flavor-paired nicotine self-administration, to examine whether sweet and cooling flavors in tobacco products enhance nicotine use behavior and addiction. Researchers will determine whether early flavor exposure and early flavorant associations with sweeteners influence subsequent nicotine choice and initiation, maintenance, and relapse. Study aims are: (1) to examine sweet and cooling flavor exposure and conditioning effects on nicotine choice and use using the two-bottle choice test in mice and nicotine self-administration in rats; and (2) to examine the effects of synthetic cooling agents on respiratory irritation caused by e-cigarette vapors. Study findings will provide new information about sweet and cooling flavor effects on the initiation and persistence of tobacco use.

Yale TCORS Project 2: Sweet and Cooling Flavors and Nicotine: Examinations in New and Established Tobacco Product Users

Evidence suggests that younger tobacco users have a greater preference for flavors compared with older tobacco users. Furthermore, youth who are initiating tobacco use often report the availability of appealing flavors as one of the primary reasons for trying and using certain tobacco/nicotine products, like e-cigarettes, cigars and hookahs. Flavors could alter the appeal and abuse potential of nicotine/tobacco either through offering appealing aroma or taste or by ameliorating aversive characteristics of tobacco/nicotine. The goal of this project is to conduct two studies to determine the influence of the “aroma and taste” and “ameliorating” attributes of popular sweet and menthol flavors on the appeal and use of e-cigarettes. Study 1 will examine the influence of brief exposures to sweet, cool and tobacco flavors (and combinations) on the appeal and abuse potential of e-cigarettes containing nicotine concentrations varying in harshness (3 and 12 mg/ml), among 60 youth (aged 16-20), who have tried e-cigarettes, do not use regularly, but plan to continue use in the future. This study will provide useful information about the influence of sensory responses to flavors on the appeal of e-cigarettes among new users. This study will also explore whether sensory responses to flavors predict emergence of e-cigarette and other tobacco use behaviors at six-month and one-year follow-ups. Study 2 will examine whether different classes of flavors (i.e., sweet, cool, tobacco), when combined with nicotine concentrations differing in harshness (6 and 18 mg/ml) alter appeal and nicotine reward among 60 young adult (aged 18-24) and 60 older adult (aged 35-50) cigarette/cigar smokers; this study will also explore the differential influence of sweet, cool, and tobacco flavors on switching from combustible tobacco product use to e-cigarettes. Findings may inform future regulatory activities related to flavors in tobacco/nicotine products.

Yale TCORS Project 3: Nicotine Delivery Rate and Its Abuse Potential: Impact of Menthol

Rapid delivery to the brain enhances the abuse potential of drugs of abuse, including nicotine. As proposed by Shihadeh and Eissenberg, nicotine flux, or the rate at which an e-cigarette delivers nicotine, is the most critical factor for evaluating its abuse potential. In this model, when an e-cigarette delivers nicotine at rates above a certain (undetermined) threshold, it can have high abuse potential and may initiate or maintain tobacco addiction. In contrast, when the nicotine flux is optimal, the e-cigarette may have low addiction potential while providing sufficient nicotine delivery to help smokers quit smoking by alleviating urges to smoke. This proposed “optimal nicotine flux” concept has yet to be assessed in human studies. In addition, flavors and other e-cigarette ingredients may affect nicotine flux; notably, menthol may have such an effect through inhibition of nicotinic receptors and slowing of nicotine metabolism. The goal of this project is to examine the impact of nicotine delivery rate on nicotine’s abuse potential and its potentially beneficial effects of alleviating smoking urges and withdrawal. Researchers will also determine whether switching from menthol to non-menthol cigarettes changes the impact of nicotine delivery rate on the study outcomes. To achieve these goals, researchers will conduct two studies in adult (aged 18-30) smokers. Study 1 will recruit equal numbers of menthol (n=35) and non-menthol (n=35) smokers for five experimental sessions, which will be at least 24 hours apart. Each session will include one randomly-assigned infusion that will be either saline or a single dose of nicotine (1 mg per 70 kg body weight) delivered at four different infusion rates (0.24, 0.096, 0.048 or 0.024 μg per kg body weight per second). In Study 2, menthol-preferring smokers (n=38) will be randomized to a menthol or non-menthol cigarette smoking condition for two weeks and will then be crossed over to the alternative smoking condition for two weeks. For both studies, the main outcome measures will be measures of abuse potential (subjective drug effects and reinforcement) smoking urges, tobacco withdrawal, plasma nicotine concentrations, nicotine metabolite ratio, heart rate, and blood pressure. Study findings may inform standards for nicotine delivery rates that minimize the addictive risks of e-cigarettes and other electronic nicotine delivery systems.

Yale TCORS: Yale Center for the Study of Tobacco Product Use and Addiction: Flavors, Nicotine and Other Constituents (YCSTP)

The Family Smoking Prevention and Tobacco Control Act prohibits adding characterizing artificial or natural flavors to tobacco cigarettes other than tobacco flavor and menthol. Menthol and a wide variety of flavors, however, are in other tobacco products. Research addressing the influence of flavors on the appeal of tobacco/nicotine and the initiation, progression and maintenance of tobacco use can inform further regulation of flavors. Toward this end, the Yale Center for the Study of Tobacco Product Use and Addiction (YCSTP) will examine the role of different classes of sweet and cool flavors, including sweeteners. on initiation, continued use and addiction to nicotine/tobacco, and their relevance to harm reduction. Researchers will integrate biological and behavioral testing in animal models and in humans to generate a firm scientific foundation for potential future regulation of flavors in tobacco products. Project 1 will examine whether preconditioning to flavors and sweeteners influences nicotine use behaviors and addiction and will evaluate the influence of novel cooling agents, which may ultimately replace menthol in tobacco products. Project 2 will examine the influence of sweet and cool flavors on initiation behaviors in youth who are susceptible to future use; it will also evaluate whether sweet and cool flavors have different impacts on nicotine reward and switching behaviors in both younger and older combustible tobacco users. Project 3 will determine the optimal delivery rate needed by tobacco users to relieve nicotine withdrawal while producing minimal positive effects, and whether the influence of this delivery rate is altered if combustible tobacco users switch from using mentholated to non-mentholated products. This TCORS may inform future regulatory activities related to flavors in tobacco products.

Leachables and Extractables in E-liquid Bottles and Closed ENDS Products

Electronic nicotine delivery system (ENDS) products can be defined as having a closed-ENDS or open-ENDS design. In closed-ENDS products, e-liquid is contained in a non-refillable reservoir; in open-ENDS products, e-liquid is contained in a refillable reservoir, and may include e-liquid drip tip devices designed to allow individual drops of liquids, waxes, or tobacco to be placed on the atomizing element. E-liquids are commonly packaged in plastic containers manufactured from a variety of polymers, co-polymers, plasticizers, colors, and other additives that may migrate or leach into the e-liquid. The goal of this study is to develop and validate a controlled extraction method to measure extractable compounds from low density polyethylene (LDPE) and polyethylene terephthalate (PET) plastic bottles with a plastic dropper and/or rubber stopper, closed ENDS devices, and e-liquid drip tips. If any of the extractables exceed the determined safety threshold, researchers will conduct a study to identify leachable compounds using the e-liquid constituents solvents propylene glycol and vegetable glycerin at various ratios, and a long-term (shelf-life) study of final packaging. Findings will provide new information about the harmful compounds that may leach into e-liquid.

CTP Supplement to Parent Grant: Monitoring the Future: Drug Use and Lifestyles of American Youth

Anecdotal reports indicate rampant youth use of JUUL; however, quantitative information about use among youth and information on use patterns, beliefs and perceptions would be useful. Researchers will add questions about JUUL and other pod-mods to the Monitoring the Future (MTF) survey, an annual nationally-representative in-school survey of 45,000 8th, 10th, and 12th grade US students. Study aims are: (1) to estimate past-month, past-year, and lifetime use prevalence of JUUL and other pod-mods among US 8th, 10th, and 12th grade students in 2019, 2020, and 2021; (2) to develop state-of-the-science survey questions on vaping frequency and topography; (3) to collect information related to JUUL and other pod-mod nicotine beliefs, methods of access, use and appeal perceptions about flavors, advertising, and abuse liability and addiction symptoms; (4) to document perception and use of JUULs in vulnerable populations by analyzing demographic and age differences in pod-mod use, attitudes, and terminology, as well as co-use of pod-mods with the 50+ other drugs and drug classes that MTF surveys; and (5) to assess trends over the next three years in pod-mod use, attitudes, and terminology with analysis of survey results from 2019 to 2021. Results will provide new information about JUUL use and related issues.

CTP Supplement to Parent Grant: Reactions to Reduced Nicotine Cigarettes in Young Adult Low- Frequency Smokers-Supplement

The goal of the parent study was to evaluate reactions to and choices of cigarettes with varying nicotine content among low-frequency, non-dependent smokers aged 18-25 years; this supplement extends the age range of the sample by recruiting and collecting data from adolescents aged 15-17 years. (Note: The research plan was developed in consultation with an expert in adolescent smoking research; all participants will be given information about smoking cessation resources.) As in the parent study, participants will undergo three sessions in which they will receive fixed doses of smoke from investigational cigarettes with three different nicotine content levels (15.8 mg/g, 2.5 mg/g, and 0.4 mg/g of tobacco). Following the third fixed-dose session, participants will return to the lab to choose one of the cigarettes to self-administer. Study aims are: (1) to combine the 15-17-year old sample with the parent grant sample and evaluates initial reactions to, and choices of, cigarettes with varying nicotine content; and (2) to identify correlates of reactions to, and choices of, cigarettes with varying nicotine content in the entire sample of low-frequency smokers. Findings will present an evaluation of the amount of nicotine in cigarette smoke that produces reactions associated with progression from initial smoking to nicotine dependence in a sample representative of individuals experimenting with cigarette use.

Support Services for Evaluating Minnesota Tobacco Policies Restricting the Sale of Flavored Tobacco Products

From 2015 to 2017, three cities in Minnesota (i.e., Minneapolis, St. Paul and Duluth) passed ordinances that restricted the sale of flavored and/or menthol tobacco products. These city ordinances provide a unique opportunity to evaluate the potential impacts of flavor restrictions. This study will employ various methods to evaluate these ordinances. Researchers will develop questions to evaluate process, outcomes, and potential unintended consequences and will use these questions to design a data collection and analysis plan. Key study components will be as follows: conducting stakeholder interviews (n=9 per interview protocol); compiling and analyzing retail scanner data; obtaining data about the implementation activities of area tobacco and liquor stores; reviewing archival data regarding enforcement and licensure; analyzing existing population survey data regarding behavior; and purchasing and visually assessing actual tobacco products in retail settings. This evaluation study will allow CTP to learn from policy development and implementation experiences; explore barriers and facilitators to policy implementation and enforcement; document policy effects on outcomes such as product availability and sales and consumer behavior; and uncover potentially unintended consequences of the policies.

User Exposure to Toxicants from Vaporized Nicotine Products

This study supplements the research objectives of a parent grant entitled, “Evaluating How Tobacco Control Policies are Shaping the Nicotine Delivery Market (P01CA200512).” In this supplemental study, researchers will evaluate the relative exposure profile of nicotine metabolites and tobacco-related carcinogens in ex-smokers using heated tobacco products (HTPs) products compared with ex-smokers using e-cigarettes, cigarette-only smokers, and never nicotine users. Using a web panel recruitment and mail-based urine sample collection strategy, researchers will examine attitudes, behaviors, and exposures in users and nonusers of HTPs and other tobacco products, including dual users of cigarettes and HTPs and/or e-cigarettes in Japan and Canada. Findings may inform future regulatory activities related to HTPs and other tobacco products.

CTP Supplement to Parent Grant: Informing Tobacco Regulatory Policy Through Laboratory Assessment of Appeal and Demand for Flavored Tobacco Products Among Young Adults

This supplement to the parent grant will address the impact of flavored tobacco product (FTP) packaging on young adult (ages 18-24) perceptions of harm, addictiveness, curiosity, and intentions to use. Specific aims are: (1) to augment the parent grant sample size from 30 to 60 to enhance the power of the parent grant’s experimental paradigm, and (2) to investigate the link between tobacco marketing techniques (i.e., packaging) with susceptibility and use of flavored e-cigarettes and little cigars/cigarillos (LCCs); this will be accomplished via two separate randomized controlled trials in which 5,600 young adults will be randomized to view one of seven pack images of an e-cigarette (n =2,800) or LCC (n = 2,800) that vary by color and flavor descriptor. Findings will provide a comprehensive assessment of factors related to FTP use and appeal.

Smokeless Tobacco Variability Lab Analysis Testing

The goal of this project is to determine the minimal number of testing replicates that provides acceptable variability in the measurement of harmful and potentially harmful constituents (HPHCs) and physical product characteristics data for smokeless tobacco products in the US. The project has two phases. Phase 1 will measure HPHCs and physical characteristics for a variety of smokeless tobacco products by systematically varying the number of test measurements and will determine the changes in analytical variability to give an optimal number of replicates. Phase 2 will use the optimum number of replicates, determined from Phase 1, and will evaluate inter-batch variability of smokeless tobacco products. Various products will be tested from common smokeless tobacco subcategories. Researchers will use published testing methods for benzo[a]pyrene, nicotine, NNN and NNK, pH, and water. A laboratory-validated method will be used to test acetaldehyde, crotonaldehyde, and formaldehyde levels. Findings will provide data regarding the number of replicates needed for reliable smokeless tobacco HPHC testing and may inform future regulatory activities.

Role of Menthol vs. Non-menthol Cigarette Smoking in Progression to Regular Tobacco Use Among Youth: Analysis of the ExPECTT Longitudinal Survey Data

The goal of this study is to investigate the role of menthol in progression to regular smoking among youth. Researchers will analyze FDA’s Public Education Campaign on Teen Tobacco (ExPECTT) longitudinal survey data to evaluate differences between menthol and non-menthol cigarette smokers in the likelihood of progression and rates of progression from never or experimental use to established smoking. Youth aged 11-16 years were enrolled in the ExPECTT study (n=6,743), and 4,210 completed all five surveys. Findings will provide new information about the use of menthol cigarettes by youth and young adults and may inform regulatory activities related to menthol.

Tobacco Consumer Studies (TCS) Panel: Brands and Purchasing Behaviors

FDA-CTP has established the National Panel of Tobacco Consumer Studies (TCS), a high-quality national panel of approximately 4,000 adult tobacco users. Panel members have the opportunity to participate in up to eight studies over a three-year period that will assess consumers’ responses to tobacco marketing, warning statements, product labels, and other communications about tobacco products. The purpose of this study, “Brands and Purchasing Behaviors,” is to describe brand preferences of cigarette, cigar, and smokeless tobacco users; examine factors associated with brand loyalty; and assess purchasing patterns and consumption. Panel members will be invited to participate in the study by completing a questionnaire on the Web using their personal devices or a loaned tablet or via mail. The questionnaire includes questions about the frequency and intensity of cigarette, cigar, and smokeless tobacco use. Current users of cigarette, cigar, and/or smokeless tobacco are asked about their usual brand; reasons for using their usual brand or for trying other brands; use of promotions such as coupons and in-store promotions; where they purchase tobacco products; and how many they purchased in the past 30 days. Study findings will provide new information about tobacco product purchasing behavior.

Hookah Purchase Journey

This study will provide information about (1) the supply chain for waterpipe tobacco and charcoal; (2) the U.S. market size for waterpipe tobacco and charcoal, with growth trends over time; (3) the costs of smoking hookah tobacco in waterpipe establishments; and (4) annual hookah unit sales. Researchers will gather qualitative and quantitative data to identify waterpipe tobacco and charcoal supply chains in waterpipe bars. For tasks involving waterpipe bars, researchers will gather information from establishments in 6-8 U.S. cities; sales data for waterpipe tobacco, charcoal, and hookah units will be determined by analyzing sales data from at least two sources, with assumptions validated by qualitative interviews. This study will provide information about the business of selling waterpipe tobacco and waterpipe-related components, and may yield insights on supply chain segments.

Consumer Perceptions of Health Claims in Vape Shops

More information about consumer perceptions of health claims related to advertising for electronic nicotine delivery systems (ENDS) would be useful, particularly advertising claims made in vape shops, which are the fastest growing segment of ENDS retailers. This study will build upon a pilot study that developed the methodology to photographically document ENDS claims in vape shops using wearable imaging technology. In this study, researchers will use this methodology to collect data related to advertising claims in vape shops. The claims from both the pilot and the new wave of data collection will be combined to create a comprehensive list of unsubstantiated claims for use in a survey that will investigate consumer perceptions of these claims. This study will provide new information about how consumers interpret real-world ENDS health claims made by retailers.

A Regulatory Impact Analysis of the FDA Warning Statement on Youth Preferences for Electronic Nicotine Delivery Systems

Since the U.S. Food & Drug Administration announced its final Deeming Rule, electronic nicotine delivery systems (ENDS) have been deemed a tobacco product and are now subject to several regulations, including a new warning statement requirement for ENDS products and advertisements that will take effect in August 2018. The goal of this project is to inform a regulatory impact analysis by evaluating the effects of the required warning statement on the likelihood that youth and young adults will purchase ENDS, and whether this effect depends on ENDS flavor. Researchers will conduct an experiment with 900 youth and young adults aged 16-25 years to address three aims: (1) to examine the effects of the ENDS warning statement on willingness to purchase and intentions to use ENDS; (2) to determine whether the effect of the warning statement on willingness to purchase is mediated by risk perceptions of ENDS; and (3) to determine whether product flavors and individual factors (e.g., demographics, tobacco use) modify the warning statement’s effect on risk perceptions, intentions to use, and willingness to purchase. In this online experiment, researchers will randomize participants into conditions varying according to the warning statement and ENDS flavor, and will be asked to complete a hypothetical purchase task. Study findings will provide new information regarding the impact of the ENDS warning statement and flavors on ENDS use, purchase intentions, and risk perceptions.

The Influence of Vaper and Smoker Identities on Young Adult Smokers Who Use Electronic Cigarettes

Smoking behavior is generally viewed negatively by others. However, identifying as a “vaper” (e-cigarette user) provides a more positive social image and allows young adult dual users to distance themselves from having a smoker identity. More information on vaper identity, how smoker and vaper identities influence each other, and how these identities influence smoking and vaping behaviors over time would be useful. Researchers will recruit 500 young adult smokers (aged 18-29 years) who initiated e-cigarette use in the past six months to complete two online surveys administered six months apart; the surveys will examine how smoking and vaping behaviors and identities change over time. Researchers will then conduct on-line individual interviews with fifty participants who complete the second survey to explore the influence of social identity and social stigma on smoking and vaping behaviors, and if/how vaping and smoking identities changed over six months. Researchers will also validate measures of vaper identity and vaping stigma scales in young adult dual users. Study findings may inform regulatory activities related to e-cigarette marketing messages and practices.

Investigating Subjective Effects and Nicotine Pharmacokinetics of Mentholated Smokeless Tobacco Products in Current Users

More information about the effects of smokeless tobacco (ST) product menthol content on the absorption of nicotine in the human body and the effect of nicotine on physiological outcomes (e.g., heart rate) would be useful. This project will examine nicotine absorption as well as the subjective and physiological effects of mentholated ST products in current users. A non-mentholated commercial ST product will be amended to produce ST products with varying levels of menthol. Adult ST users will attend five laboratory sessions and receive a prescribed amount of ST at each session under the following conditions: (1) usual brand ST, (2) non-mentholated ST, (3) ST with low menthol content, (4) ST with medium menthol content, and (5) ST with high menthol content. Physiological measures (e.g., heart rate, blood pressure) and subjective measures (e.g., self-reports of how much participants like the product) will be assessed before, during, and after prescribed use. Researchers will also collect blood and urine samples at each session to assess plasma nicotine concentration and other biomarkers of exposure. Study findings will provide new information that may help inform regulatory activities.

Assessment of Genotoxic Potential of Serially Diluted Whole Tobacco Smoke using Ames, Micronucleus, and Pig-A Assays

Information about the genotoxic (gene toxicity) potential of whole smoke generated from commercial cigarettes is useful in evaluating health risk. The goal of this study is to test the genotoxicity of diluted whole smoke generated from research and commercial cigarettes using three standard genotoxicity assays (the Ames test, the micronucleus assay, and the Pig A assay). The top eight cigarettes in the U.S. will be selected based on their market volume. Researchers will use an air-liquid interface cell exposure system to expose human bronchial epithelial cells and cardiac cells to diluted whole smoke generated using the International Standards Organization (ISO) and Health Canada Intense (HCI) smoking regimens. Researchers will measure levels of tar/nicotine/carbon monoxide (TNCO), acrolein, acetaldehyde, tobacco-specific nitrosamines (NNN and NNK), formaldehyde, and benzo[a]pyrene. Total particulate matter and gas-vapor phase from the mainstream smoke will also be tested separately using both smoking regimens for comparison purposes. Study findings will provide new information regarding the genotoxic effects of cigarette smoke.

Inhalation Study of the In Vivo Toxicity of Essential Oils

Some essential oils used in tobacco products – including cinnamon bark oil, cinnamon leaf oil, and sage oil — have been shown in in vitro studies to be toxic or are believed to possess toxic properties based on scientific literature. The aim of this study is to determine the inhalation toxicity of these three essential oils in rats and use these data to estimate potential inhalation toxicity in humans. In three 14-day dose-ranging studies (one per oil), researchers will expose rats to aerosol generated from the oil and determine the threshold concentration that can cause non-lethal/non-painful/non-stressful effects and the maximum tolerable dose (or maximum feasible dose). In three sub-acute 28-day studies (one per oil), researchers will characterize the dose response of each oil and determine the no observed adverse effect level (NOAEL), no observed effect level (NOEL), lowest observed adverse effect level (LOAEL), and lowest observed effect level (LOEL). The objective of the 14-day studies is to determine the starting dosages for the 28-day studies based on clinical signs, whereas the objective of the sub-acute studies is to observe and quantify toxicity in all organs, especially the nasopharyngeal tissue, respiratory tract and lungs. Study findings will help determine the potential for human health effects from exposure to inhaled essential oils and may inform regulatory activities related to tobacco product additives/ingredients.

In Vitro Detection and Characterization of DNA Adducts Generated by Tobacco Flavorants in Aerosol Using ALI

Tobacco products contain flavor chemicals that have been determined to be “generally recognized as safe” (GRAS) for food products, but for tobacco products, flavor chemicals may be harmful when the flavors themselves or flavor combustion products are inhaled. Researchers will identify DNA adducts for selected tobacco flavors in five different lung or respiratory tract cell types. DNA adducts are formed by chemicals that bind to pieces of DNA, which causes modifications of the DNA. If these modifications are not repaired, cancer may develop. Over two years, five lung or respiratory cell lines that express specific P450 or sulfurtaransferase enzymes will be used to detect DNA adducts from the selected flavors. The researchers will conduct dose-response experiments to develop and confirm the methods for quantifying specific DNA adducts. Based on these dose-response experiments, researchers will then investigate in vitro air-liquid interface (ALI) aerosol exposures of the cell lines by adding a flavoring to a propylene glycol/vegetable glycerin solution and measuring the formation of adducts. Study results will provide new information about the health risks associated with tobacco flavorings.

Genotoxicity Assessments of Flavoring Ingredients in ENDS Product

More information about the potential of flavoring ingredients to cause genotoxicity (gene toxicity) would be useful. The primary objective of this study is to conduct a high throughput mammalian cell genotoxicity study using commercially-available validated genotoxicity screening assays. The results from the screening assays will indicate whether a flavor ingredient is potentially genotoxic and, for those that are positive, describe the mechanism of action of the genotoxic effects. The secondary objective is to conduct statistical quantitative structure-activity relationship (QSAR) and structure-activity relationship (SAR) analyses for predicting the genotoxicity of the flavoring agents tested in the screening assay. Comparing the results of the QSAR and SAR analyses with the findings of the in vitro screening assays will help in the creation of a predictive model for genotoxicity assessment of the flavoring ingredients in tobacco products.

Cytotoxicity of Common Solvents used in Liquid Nicotine Formulations

This study aims to establish the baseline toxicity of propylene glycol (PG) and vegetable glycerin (VG), the primary solvents in e-liquid, as well as the effect of temperature and heating element composition on solvent-induced cytotoxicity (cell toxicity) with and without nicotine co-exposure. The first part of the study will involve measurement of in vitro cellular toxicity using human bronchial epithelial cells. The cells will be exposed to e-cigarette aerosol produced with e-liquid mixtures with varying ratios of PG and VG. The second part of the study will involve separately changing two parameters: (1) the power output of the device relative to the setting used in the first part of the study, and (2) the constituent materials used in the heating element. The heating element materials tested will include Kanthal, nichrome, stainless steel and ceramic; the solvent formulations used will be the three formulations that showed the greatest cytotoxicity in the first part of the study. Chemical characterization of the aerosol will include identification and quantification of chemical constituents, total particulate matter (TPM), pH, and particle size distribution. Study findings may inform the development of a potential in vitro toxicity screening protocol for e-cigarettes.

Understanding How Flavors are Used in Advertisements for Electronic Nicotine Delivery Systems (ENDS)

More information about the marketing of flavored electronic nicotine delivery system (ENDS) products would be useful. Researchers will analyze U.S. advertisement content and associated audiences for e-cigarette products to understand how flavors are portrayed and which sub-populations are seeing which flavored product advertisements. The ads will be purchased through media tracking services and coded by researchers for descriptive content, including how flavors are portrayed in the physical composition/ad format (e.g., size, image, setting) and the content of the ad (e.g., descriptors, themes). For example, e-liquids (e.g., berry, mint) may be described in ads as smooth or fresh (descriptors traditionally used for cigarette or other tobacco products), as delicious or satiating (suggesting the product could be used as a hunger suppressant), or as fun and novel. The media tracking services provide information about the media platform the ads appeared in and the general audience meant for each platform, allowing the ad content to be associated with an audience. Study findings may inform regulatory activities related to flavored e-cigarette product marketing and advertising.

Qualitative Study on Nicotine Exposure Risk: Knowledge, Beliefs, Perceptions, and Behaviors

Researchers will conduct a qualitative study to gain insight on consumer knowledge and perceptions surrounding risk of acute toxicity due to nicotine exposure. In addition, consumers will be asked to view a variety of draft electronic nicotine delivery systems (ENDS) warnings for e-liquid nicotine toxicity. A total of twelve focus groups will be conducted with 104 participants. Of these, eight focus groups will be conducted with young adult (aged 18-24) and adult (aged 25-65) ENDS users. In addition, four focus groups will be conducted with youth (aged 13-17) who have used or currently use ENDS. Focus groups will discuss what adults and youth know about acute toxicity due to exposure to e-liquids, the best ways to present information about e-liquid nicotine toxicity to consumers, and reactions to draft ENDS warnings for acute nicotine toxicity.

Evaluation of Metal Ions in Electronic Cigarette Aerosol Condensates and Determination of their Effects on Oral Keratinocytes

Several reports suggest that toxic metal ions and harmful and potentially harmful constituents (HPHCs) are present in e-cigarette aerosol condensates. It is unknown whether metal ions or the potential presence of HPHCs in e-cigarette aerosol condensates can trigger adverse biological responses in oral keratinocytes, the primary oral cavity cells targeted by potential toxicants. In this study, researchers will develop an integrated approach that will (1) generate and collect e-cigarette aerosols in a manner that mimics user inhalation and (2) uses inductively coupled plasma mass spectrometry to identify metal ions (e.g., lead, tin, cadmium, iron, copper, zinc) and HPHCs present in aerosol condensates. This approach will include exposing normal oral keratinocytes to aerosol condensates and then assessing their ability to divide and identifying signs of toxicity. Researchers will assess several e-cigarette brands and tobacco- and menthol-flavored e-liquids. This approach will provide a quantitative analysis of the metal ions present in e-cigarette aerosol condensates and oral cavity cells.

Cognitive Interviews with Adult E-cigarette Users Designed to Inform CTP Infographic and Website Content

Some of the adverse experiences associated with electronic nicotine delivery systems (ENDS) that have been reported to FDA include burns and injuries resulting from battery explosions. CTP has developed a set of materials (an infographic, shareable images, and website content) to educate consumers about the risks of battery explosions when using e-cigarettes. Researchers will conduct a qualitative study to gather information about the utility of these materials in helping consumers avoid an e-cigarette battery explosion. Qualitative and in-depth interviews will be conducted with nine participants, including four young adults (aged 18-25) and five adults (aged 26-65) who are current established and experimental e-cigarette users. The interviews will be conducted at professional focus group and interviewing facilities in Arlington, VA. Potential participants will be recruited and screened by the interviewing facilities. One-on-one interviews will be facilitated by a professional moderator using a structured moderator guide. Study findings will be used to refine the existing content and inform the development of future materials.

Impact of Exclusive Use of Low Nicotine Cigarettes on Compensatory Smoking

Clinical trials evaluating reduced nicotine content cigarettes generally have not found evidence of compensatory smoking behaviors among participants; however, most participants in low nicotine groups use non-study cigarettes, despite explicit instructions to use only the study cigarettes provided to them. The aim of this study is to test the impact of nicotine reduction on smoking behavior and toxicant exposure when participants do not have access to normal nicotine content cigarettes. Twenty adult smokers (aged 18 years and older) will be confined to a hotel setting for two four-night stays during which they will only have access to research cigarettes. During one hotel stay they will have access to normal nicotine content cigarettes, and during the second hotel stay they will only have access to very low nicotine content cigarettes. Participants will purchase all of their cigarettes using a study bank, and will be able to purchase up to three packs of cigarettes per day. To assess whether smokers engage in compensatory smoking (e.g., smoking more cigarettes, taking longer puffs) as a result of nicotine reduction, biomarkers of smoke and toxicant exposure (e.g., expired carbon monoxide) and behavioral measures of smoking (e.g., cigarettes smoked per day, puff topography) will be compared between the two conditions. This study will provide new information about the effects of reduced nicotine content cigarettes.

Effect of Banning Menthol Flavorant on Cigarette and e-Cigarette Use

More information about how menthol flavoring in e-cigarettes affects overall tobacco use would be useful. This study will obtain preliminary information regarding how a menthol ban that either exempts or includes e-cigarettes is likely to affect overall tobacco use. In this six-week study, researchers will assign menthol cigarette smokers to one of three conditions: (1) a condition simulating a ban on menthol cigarettes but not menthol e-cigarettes; (2) a condition simulating a ban on both menthol cigarettes and menthol e-cigarettes; and (3) a condition in which menthol is not banned for either product (the control condition). Tobacco product use, motivation to quit, number of quit attempts, and support for a menthol ban will be assessed. Data from this study will be used to plan larger studies examining how menthol flavoring in e-cigarettes affects tobacco product use patterns and toxicant exposure.

Using Concept Mapping to Inform the Measurement of Flavor Outcome Expectancies among Young Adults; CTP Supplement to Parent Grant: Center for the Study of Tobacco Products

Flavor additives in e-cigarettes may play a role in e-cigarette initiation, dual use, and switching among young adult combustible tobacco product (cigarette/little cigar/cigarillo) smokers, but gaps remain in the availability of measurement tools that can assess how flavors influence e-cigarette use behaviors. The goal of this study is to develop a flavor outcome expectancies scale that can help quantify the role of flavors in e-cigarette trajectories among young adult cigarette and/or little cigar/cigarillo smokers. This study builds on five previously-completed concept mapping studies that yielded more than 100 user-generated statements that describe positive and negative flavor experiences. Study aims are: (1) to use the statements to develop items for the flavor outcome expectancies scale; (2) to establish the content validity of the scale and test the scale items using cognitive interviews; and (3) to pilot test the scale, examine the internal consistency and factor structure, and investigate the concurrent and construct validity of the scale. First, researchers will reduce and revise relevant concept mapping statements and obtain feedback from an expert panel on the content validity and structure of the items. Next, researchers will conduct cognitive interviews (n=10) and focus groups (n=24) among young adult cigarette and/or little cigar/cigarillo smokers ages 18-35 to examine their understanding of the items. Finally, researchers will recruit smokers who have never used e-cigarettes (n=140) and smokers who currently use e-cigarettes (n=140) to complete an online survey that will allow the researchers to examine the structure of the scale and test its validity. This project will provide new information about the role of flavors in e-cigarette initiation, dual use, and switching by young adult smokers.

CTP Supplement to Parent Grant: Metals in Electronic Cigarette Aerosol

This study is a supplement to a parent study that sought to identify and quantify the metal content of e-cigarette aerosols from various products and designs, to examine the cell and gene toxicity of aerosols with metal content, and to examine biomarkers of metal exposure and health effects in e-cigarette users. E-liquids often contain high concentrations of the flavor chemicals menthol (M-ol) and/or menthone (M-one) and cinnamaldehyde (CAD). This supplemental project will: (1) identify and quantify flavor chemical degradation products formed by vaping e-liquids containing M-ol, M-one, and CAD; and (2) determine which in vitro assays best assess the toxicity of e-cigarette aerosols and which reaction products cause toxicity. This study will provide new information about e-cigarette aerosol toxicity.

Evaluation of E-Cigarette Aerosol in In Vivo Nonclinical Models

Additional information about inhaled e-cigarette aerosol toxicity would be useful. In this study, researchers will first conduct a seven-day pharmacokinetic nose-only inhalation study in female rats exposed to e-cigarette aerosol generated by three commercially-available devices. Researchers will test low, medium, and high nicotine doses based on potential human exposure with e-cigarette use. Blood and urine nicotine biomarkers will be collected to determine e-cigarette aerosol nicotine dose exposure levels. Researchers will also conduct a 90-day nose-only inhalation sub-chronic study in female rats to examine in vivo aerosol toxicity using three e-cigarette devices; exposure concentrations will be based on the data from seven-day study. Data gathered will include aerosol concentration measurements; measurements such as food consumption, body weight and food/water consumption; clinical observations; and urinary biomarkers of exposure. Study findings will inform characterization of the dose-response relationship and potentially identify a maximum tolerated dose without substantial toxicity.

Perceptions of Nicotine and Relative Harm of Tobacco Products in U.S. Young Adults

Existing studies on tobacco harm perceptions have largely focused on the tobacco products themselves without addressing perceptions of nicotine separately. This study seeks to provide new information about the interplay between nicotine harm perceptions and tobacco product harm perceptions and how these perceptions affect tobacco use susceptibility and population-level tobacco use patterns. Researchers will conduct secondary analyses of longitudinal data from a large, national sample of U.S. young adults (4,100 young adults aged 18-34 years) using new measures of nicotine harm perceptions to examine the perceived harm of nicotine, the relative harm of tobacco products, and the impact of these perceptions on tobacco-related intentions and behavior. Study aims are: (1) to examine perceptions of nicotine and relative harm of tobacco products in a national sample of U.S. young adults and identify correlates of these perceptions (e.g., sociodemographics, tobacco use); (2) to characterize young adult subgroups based on their perceptions of nicotine and relative harm of tobacco products using latent class analysis; and (3) to describe the impact of nicotine and tobacco harm perception “class” on longitudinal patterns in susceptibility and curiosity to use tobacco and tobacco use behavior. Study findings will provide new information related to tobacco product and nicotine harm perceptions, and may inform regulatory activities related to tobacco product warning labels and other public education efforts.

Evaluation of Micronuclei and DNA Damage in B6C3F1 Male Mice Administered 4-(Methylnitrosamino)-1-(3-Pyridyl)-1-Butanone by Intraperitoneal Injection

The tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) is on FDA’s published list of harmful and potentially harmful constituents (HPHCs) in smokeless tobacco products and tobacco product smoke. NNK is a strong lung carcinogen, causing lung tumors in a variety of laboratory animals, including mice. This study will evaluate the gene toxicity potential of NNK in live animals using a micronucleus and comet assay study. Researchers will treat mice with NNK or a positive control chemical and evaluate the animals for genetic toxicity. Researchers will assign five male mice to each one of three experimental groups (NNK, positive control, and negative control) and will administer the respective treatments for three consecutive days. After exposure, they will collect blood and bone marrow cells for micronuclei frequency assessment (chromosomal abnormalities that serve as surrogates for carcinogenic potential) and liver, lung, and bone marrow for DNA damage assessment. Study findings will provide information regarding the genotoxic and chromosomal damage profile of NNK and the carcinogenicity mode of action for NNK.

CTP Supplement to Parent Grant: Interactions between Tobacco Smoke Constituents in Rodent Tumor Models

This study is a supplement to a parent project that sought to characterize the potential interactions between known human carcinogens (e.g., NNK, NNN, BaP) and volatile components of tobacco smoke (e.g., acetaldehyde, acrolein, formaldehyde) in established rodent tumor models. This study will add a histopathological analysis (an analysis of tissue changes) to the previous study analyses; histopathological analysis will provide additional useful information for the detection of the interaction between acetaldehyde or formaldehyde (two tobacco-associated lung carcinogens) and NNK. Taken together, these analyses will provide important information about the ability of volatile compounds to influence the tumor-generating activity of established tobacco carcinogens.

CTP Supplement to Parent Grant: Evaluating Concomitant Use of Very Low Nicotine Content Cigarettes and E-cigarettes Among Daily and Non-Daily Smokers on Abuse Liability

This study is a supplement to a parent study that modeled abuse liability in a market in which the combustible cigarette nicotine level was lowered to meet a potential regulatory standard, but an alternate source of nicotine in the form of e-cigarettes was also available. The coexistence of these products raises questions about whether the potential public health benefit of reducing abuse liability with low nicotine cigarettes might be offset by the concurrent use of e-cigarettes. In this supplemental study, researchers will quantify the formaldehyde DNA adduct N6-hydroxymethyldeoxyadenosine in leukocyte DNA samples collected via cheek swabs of 160 adult e-cigarette users aged 18-65. This will provide a measure of exposure to a potential toxicant specific to e-cigarettes, and will complement the biomarkers of combustible tobacco and nicotine exposure included as part of the parent study.

Chemical Analysis of Mainstream Smoke from Cigarillos, Large Cigars and Reference Cigarettes to Determine the Amount of Carbonyls

This task order is a continuation of a project to measure specific harmful and potentially harmful constituent (HPHC) quantities in a variety of currently-marketed cigarillos, large cigars and reference cigarettes using a validated testing method. Acrolein is a chemical compound that has been identified as a significant contributor to tobacco products’ non-cancer respiratory effects (such as chronic obstructive pulmonary disease, or COPD). This study will measure the acrolein yields of commercial cigar tobacco products (10 cigarillos and five large cigars) using the CORESTA No. 74 recommended method under the ISO and Canadian Intense smoking regimens. Additional analysis using reference cigarettes may help identify sources of variability (i.e., whether variability is due to the smoking regimen or the cigar products themselves) in the data generated for the cigarillo and cigar products. This study may help identify a recommended method to determine acrolein levels in cigars and cigarillos.

Establishing Matrix-Specific Harmful and Potentially Harmful Constituents Lists (Phase 2, Task Order 1)

More information about which harmful and potentially harmful constituents (HPHCs) are present in specific types of tobacco samples – particularly the newly deemed tobacco products — would be useful. The primary goal of this study is to establish product/sample type-specific HPHC lists through laboratory testing. A second goal is to establish baseline values for the HPHCs present in each product/sample type. Products will be selected for testing based on market volumes, product features, and types/subcategories. Because of its broad scope, this study includes three phases, with one or two task orders under each phase. In Phase 2-Task Order 1, testing will focus on roll-your-own tobacco, pipe tobacco, cigar tobacco, and cigar smoke. HPHCs to be investigated will include aflatoxin, amide, metals, non-tobacco specific nitrosamines, PAHs, phenols, tobacco specific alkaloids, dioxins, heterocyclic aromatic amines, and hydrazine. Study findings may inform regulatory activities related to product testing, reporting, and evaluation.

Reduction in Carbonyl Yields from Sheet-Wrapped Cigars by Charcoal Filtration

Carbonyl compounds, including formaldehyde, acetaldehyde, and acrolein, are harmful and potentially harmful constituents (HPHCs) present in the gas and particulate phases of the mainstream smoke of combusted tobacco products. Carbon-based materials like charcoal, which have a large surface area and are porous, have been incorporated into cigarette filters to capture HPHCs, including carbonyls, from mainstream cigarette smoke with varying degrees of effectiveness. However, more information about charcoal filtration in sheet-wrapped cigars would be useful. The goal of this project is to evaluate the effect of charcoal filtration on carbonyl reduction in the mainstream smoke of sheet-wrapped cigars. Researchers will modify currently marketed sheet-wrapped cigars with an adapted filter design that incorporates charcoal into the filter at varying quantities, and will measure carbonyl levels in the resulting mainstream smoke. Study findings may inform the development of technologies that could reduce levels of carbonyl and other HPHCs in the smoke of sheet-wrapped cigars.

Menthol Use in Roll-Your Own Tobacco and Little Cigars and Migration

Menthol is a common flavor additive that masks harshness and makes smoking tobacco more appealing. To better understand menthol application and migration in combusted tobacco products, menthol will be quantitatively determined in select cigarette, little cigar, and roll-your-own tobacco (RYO) tobacco products. Additionally, researchers will apply defined quantities of menthol to either the filter, tobacco rod, or packaging of various commercial non-menthol cigarettes and little cigars and measure the menthol in these components at different storage times. Researchers will also measure the menthol in the mainstream smoke from these products. Information from this study will expand upon our previous research activities related to menthol in combusted tobacco products and how its application and physical properties may influence its transfer to mainstream smoke.

Establishing Matrix-Specific Harmful and Potentially Harmful Constituents Lists (Phase 2, Task Order 2)

More information about which harmful and potentially harmful constituents (HPHCs) are present in specific types of tobacco samples – particularly the newly deemed tobacco products — would be useful. The primary goal of this study is to establish product/sample type-specific HPHC lists through laboratory testing. A second goal is to establish baseline values for the HPHCs present in each product/sample type. Products will be selected for testing based on market volumes, product features, and types/subcategories. Because of its broad scope, this study includes three phases, with one or two task orders under each phase. In Phase 2-Task Order 2, testing will focus on pipe tobacco, cigar tobacco, and cigar smoke. HPHCs to be investigated will include coumarin, hydrogen cyanide, PAHs, non-tobacco specific nitrosamines, caffeic acid, ethyl carbamate, and tobacco specific alkaloids. Study findings may inform regulatory activities related to product testing, reporting, and evaluation.

Establishing Matrix-Specific Harmful and Potentially Harmful Constituents Lists (Phase 3, Task Order 2)

More information about which harmful and potentially harmful constituents (HPHCs) are present in specific types of tobacco samples – particularly the newly deemed tobacco products — would be useful. The primary goal of this study is to establish product/sample type-specific HPHC lists through laboratory testing. A second goal is to establish baseline values for the HPHCs present in each product/sample type. Products will be selected for testing based on market volumes, product features, and types/subcategories. Because of its broad scope, this study includes three phases, with one or two task orders under each phase. In Phase 3-Task Order 2, testing will focus on hookah tobacco and smokeless tobacco products. HPHCs to be investigated will include amide, caffeic acid, coumarin, ethyl carbamate, hydrogen cyanide, non-tobacco specific nitrosamines, polycyclic aromatic hydrocarbons, and volatiles. Study findings may inform regulatory activities related to product testing, reporting, and evaluation.

Hookah Smoking, Carbon Monoxide, and Coronary Endothelial Function

Because hookah tobacco is heated with burning charcoal, hookah smoke contains charcoal combustion products including carbon monoxide (CO) and oxidants that can clog coronary arteries. The CO level associated with hookah use decreases oxygen delivery to the heart unless it is offset by increased blood flow. The goals of this study are: (1) in young healthy hookah smokers, to test if CO dilates the heart’s arteries, thereby masking a tobacco-induced impairment; and (2) in long-term middle-aged hookah smokers, to test: (a) whether the coronary endothelium (the tissue lining the heart’s arteries) has become too dysfunctional to respond to CO in hookah smoke, thereby indicating impaired blood flow to the heart; and (b) whether the reduced blood flow is large enough to stress the heart. Heart function will be measured as the increase in heart blood flow caused by handgrip exercise. Blood flow in the heart will be measured by ultrasound. The handgrip-induced increase in blood flow will be measured in younger and older hookah smokers before and after smoking charcoal-heated or electrically-heated hookah tobacco, and, for comparison, in age-matched cigarette smokers before and after smoking two cigarettes. Specific aims are: (1) to determine the acute effect of hookah smoking on blood flow to the heart in 24 healthy young adult hookah smokers (aged 21-25 years), compared to 12 young adult cigarette smokers; 2) to determine the acute effect of inhaled CO gas alone (to mimic the hookah-induced CO level of 25 ppm, generally considered to be non-toxic) on blood flow to the heart in a subset of 16 young adult hookah smokers; and (3) to determine the acute effect of hookah smoking on blood flow and heart function in 12 long-term middle-aged hookah smokers (aged 35-49 years), compared to 12 middle-aged cigarette smokers. Study findings may provide new understanding of how hookah smoking impacts the regulation of blood flow to the heart in both young and middle-aged adults.

Establishing Matrix-Specific Harmful and Potentially Harmful Constituents Lists (Phase 1, Task Order 1)

More information about which harmful and potentially harmful constituents (HPHCs) are present in specific types of tobacco samples – particularly the newly deemed tobacco products — would be useful. The primary goal of this study is to establish product/sample type-specific HPHC lists through laboratory testing. A second goal is to establish baseline values for the HPHCs present in each product/sample type. Products will be selected for testing based on market volumes, product features, and types/subcategories. Because of its broad scope, this study includes three phases, with one or two task orders under each phase. In Phase 1-Task Order 1, testing will focus on cigarette smoke, cigar smoke, and smokeless tobacco products. HPHCs to be investigated will include metals, amides, aromatic amines, carbonyls, polycyclic aromatic hydrocarbons, non-tobacco specific nitrosamines, and phenols. Study findings may inform regulatory activities related to product testing, reporting, and evaluation.

Refilling Addiction: Investigating Marketing for E-liquid on Instagram

E-cigarette use has been steadily increasing in the U.S. over the past decade, particularly among adolescents and young adults. The liquids used in refillable e-cigarette devices (e-liquids) often contain nicotine and are sold in a range of appealing flavors and colors. At present, there is little understanding of how e-liquids are marketed on social media or which social media marketing elements are most appealing and persuasive to young adults. Instagram, a social media platform in which each post contains an image or short video, is used by over half of all U.S. adolescents and young adults who use the Internet; exploratory research suggests that Instagram is home to a large volume of e-liquid posts. The goal of this study is to investigate e-liquid marketing on Instagram. Study aims are: (1) to document the ways in which e-liquid manufacturers and retailers market their products on Instagram, and (2) to discern how young adults interpret and respond to e-liquid marketing on Instagram. Investigators will perform a content analysis of 2,000 Instagram posts with the hashtags #eliquid and/or #ejuice to identify marketing themes and claims, promotional strategies, and products promoted. They will analyze health, harm reduction, and cessation claims, as well as products and marketing strategies known to appeal to youth. Investigators will draw posts from four time periods in 2017 and 2018 in order to capture changes in content over time. Additionally, they will track the total number of posts with each hashtag to determine trends in the volume of e-liquid activity. In addition to the content analysis, investigators will hold 12 focus groups with a total of approximately 72 18-24 year olds in Milwaukee, WI who use Instagram. Focus groups will identify participant interpretations and responses to actual Instagram marketing posts.

E-Cigarette Vaping in Advertising Portrayals and Behavioral Outcomes Research (E-VAPOR Study)

Young adults have the highest prevalence of dual use of cigarettes and e-cigarettes (current smokers who also use e-cigarettes). Little is known about the causal links among young adult exposure to vaping images in e-cigarette advertisements, urge to smoke conventional cigarettes, and objective measures of conventional cigarette smoking intensity. The goal of this study is to identify key factors in tobacco advertising that influence young adult smoking. Investigators will conduct a randomized controlled experiment among 210 young adult dual users aged 21-30 years. Specific aims are: (1) to demonstrate the causal link between vaping portrayals in e-cigarette ads and subjective measures of urge to smoke among dual-users, and (2) to demonstrate the causal link between vaping portrayals in e-cigarette ads and objective measures of smoking intensity based on puffing topography measures. Participants will be randomly assigned to one of three video conditions: e-cigarette ads containing vaping portrayals, e-cigarette ads edited to remove vaping portrayals, or neutral videos. Each participant will view eight 30-second ads within each condition for a total of four minutes of ads, and ads will appear in random order. After viewing the ads, participants will complete the Questionnaire on Smoking Urges-Brief (QSU-Brief) instrument and will smoke their own brand of cigarettes so that investigators can measure puffing topography (puff number, volume, duration, interpuff interval, and flow rate).

The Real Cost General Market: Wave 4 Creative Concept Testing Designed to Prevent Youth ENDS Use

Researchers will conduct a qualitative research study to inform the development of appropriate messaging to prevent the use of electronic nicotine delivery systems (ENDS) among youth (aged 12-17). Specifically, this study will use focus groups to explore the target audience’s reactions to various creative advertisement concepts and messaging probes intended to prevent youth ENDS use. Approximately 24 focus groups with up to 8 participants each will be conducted in various locations across the U.S. for a total sample of up to 192 youth. Participants will be youth who: (1) are at-risk of initiating ENDS use; (2) are ENDS-only experimenters (do not use or experiment with combustibles); and (3) have experimented with cigarettes and ENDS (dual experimenters). Participants will be diverse in terms of race/ethnicity, gender, and geographical location. Findings will inform public education campaign messaging about ENDS.

The Real Cost Smokeless: Wave 2 In-depth Interviews Designed to Prevent Rural Youth Tobacco Use

In support of FDA’s efforts to refresh youth tobacco prevention campaign messaging, researchers will conduct a qualitative research study to gain a richer understanding of the target audience, including their home life, values, and exposure to smokeless tobacco. In-depth interviews will be conducted in three geographically distinct rural regions with 22 male adolescents aged 12-17 years who are at risk for smokeless tobacco use, experimenting with smokeless tobacco, or established users of smokeless tobacco. Interviews will be conducted in schools and will include a mix of races and ethnicities. This study will inform the development of appropriate messaging for subsequent waves of FDA’s The Real Cost Smokeless campaign.

TRC Smokeless Wave 2 Creative Concept Testing – Focus Groups With Rural Youth

Researchers will conduct a qualitative research study to inform the development of a new set of messages for Wave 2 of FDA’s The Real Cost Smokeless campaign. Focus groups will be conducted in four rural regions with male youth aged 12-17 years who are at risk for smokeless tobacco use or who are experimenting with smokeless tobacco. Researchers will conduct 18-24 focus groups with four to eight students each (for a maximum of 144 participants). Focus groups will be segmented by school level (middle or high school), smokeless tobacco status (at risk or experimenter) and race/ethnicity (Non-Hispanic White or all other races and ethnicities besides Non-Hispanic White). Focus groups will explore reactions to various creative concepts intended to prevent youth smokeless tobacco use. Findings will contribute to the development of appropriate educational campaign messaging.

Developing Strategic Concepts Designed to Prevent AI/AN Youth Tobacco Use

This study will involve qualitative research to inform the development of a public education campaign to discourage use of cigarettes by American Indian/Alaska Native (AI/AN) youth. Researchers will conduct focus groups with up to 168 U.S. AI/AN youth aged 12-17 who are experimental tobacco users and susceptible non-triers. Participants will be recruited using a community-intercept approach, and groups will be conducted in both community and commercial focus group facilities. Focus group activities will include individual surveys, facilitator-led activities, and group discussions. The activities are designed to provide insight into youth perceptions related to local teen cultures and tobacco use attitudes, beliefs, and perceptions. Findings will provide information to inform campaign development.

Creative Concept Testing Designed to Prevent Youth and Young Adult Smoking

In 2014, FDA launched its first youth tobacco education campaign, called The Real Cost, targeting at-risk youth aged 12-17. In 2018, the FDA expanded its public education campaigns to focus on the prevention of youth electronic nicotine delivery systems (ENDS) use. To support these efforts, the FDA’s Center for Tobacco Products (CTP) will conduct a qualitative research study to inform the development of appropriate campaign messaging to prevent combustible cigarette smoking and other nicotine use among youth and young adults. Focus groups will explore participants’ reactions to various creative advertisement concepts. Approximately 30 focus groups with up to eight participants each will be conducted remotely across the U.S. with a total sample of up to 240 youth (ages 13-17) and young adults (ages 18-20) who are at risk of initiating cigarettes (susceptible) or have experimented with cigarettes (experimenter). Discussion groups will include a diversity of participants and will be segmented by cigarette usage (i.e., experimenter/susceptible) and by age. Findings will inform messaging included in future tobacco education campaigns.

Establishing Matrix-Specific Harmful and Potentially Harmful Constituents Lists (Phase 1, Task Order 2)

More information about which harmful and potentially harmful constituents (HPHCs) are present in specific types of tobacco samples – particularly the newly deemed tobacco products — would be useful. The primary goal of this study is to establish product/sample type-specific HPHC lists through laboratory testing. A second goal is to establish baseline values for the HPHCs present in each product/sample type. Products will be selected for testing based on market volumes, product features, and types/subcategories. Because of its broad scope, this study includes three phases, with one or two task orders under each phase. In Phase 1-Task Order 2, testing will focus on cigarette smoke, cigar smoke, and smokeless tobacco products. HPHCs to be investigated will include aflatoxin, coumarin, non-tobacco specific nitrosamines, volatiles, heterocyclic aromatic amines, and hydrogen cyanides. Study findings may inform regulatory activities related to product testing, reporting, and evaluation.

Associations of Youth E-Cig and Tobacco Use: Ecological Momentary Assessment

Research suggests that socio-ecological factors, such as e-cigarette access, perceptions, marketing, and use by others, may increase youth susceptibility to future use of combustible tobacco products. This study will use a longitudinal ecological momentary assessment (EMA) approach and a computer-assisted self-interview survey to examine both within-person and between-person associations of factors related to e-cigarette and tobacco use, use intentions, willingness to use, and the role of environment and situational factors on adolescent use of e-cigarettes and tobacco. Data will be collected from 50 adolescents (ages 13-17) who are e-cigarette only users or dual users of e-cigarettes and tobacco and who live in Kentucky, a state where e-cigarette use rates are three times higher than the national average for middle schoolers and two times higher than the national average for high schoolers. Specific aims are: (1) to investigate within-person associations among e-cigarette and tobacco access, motivations, exposure, context, intentions, willingness, and behaviors; (2) to investigate between-person associations among e-cigarette and tobacco beliefs, norms, access, motivations, exposure, context, intentions, willingness, and behaviors; and (3) to explore differences between e-cigarette only users and dual users regarding e-cigarette and tobacco beliefs, access, motivations, exposure, context, intentions, willingness, behaviors, and personal risk factors. Study results may provide preliminary data to guide the design of the larger, more rigorous studies about e-cigarette initiation, use, perceptions, and transition to other tobacco products.

E-Cigarette Warning Labels: Tests of Messages to Reduce Recreational Use among Adolescents

Recreational use of e-cigarettes by non-smoking youth has increased dramatically in recent years. This study tests warning label alternatives in the context of other product information to identify communication strategies that minimize youth recreational uptake of e-cigarettes. Specific aims are: (1) to determine the impact of three different e-cigarette warning labels on adolescents’ perceptions of the product; (2) to determine whether a modified risk statement near the warning label changes how adolescents perceive the product; and (3) to determine whether the mention of a novelty flavor near the warning label changes how adolescents perceive the product. Investigators will present 650 ninth and tenth graders with a randomly assigned warning label that varies by the type of consequence mentioned in the warning label (3 variables) as well as whether or not the package features a modified risk statement (“This product presents a lower risk of tobacco-related disease than traditional cigarettes”; 2 variables) and/or the mention of any one of three sweet novelty flavors to be determined (2 variables); the 3x2x2 study design, plus one control condition, will yield 13 possible experimental labels. The three warning labels are: (a) one specific consequence (FDA text: WARNING: This product contains nicotine. Nicotine is an addictive chemical.); (b) multiple specific consequences (a 117-word warning that was proposed by the MarkTen manufacturer); or (c) an abstract consequence (WARNING: The long-term health risks associated with this product are unknown.). Participants will then complete an iPad survey that includes both newly-developed questions and questions from previously-validated surveys such as the Youth Tobacco Study and the Population Assessment of Tobacco and Health Study; outcomes measured will include risk perceptions, message comprehension, harm-minimizing beliefs, susceptibility, and behavioral intentions toward e-cigarette uptake. Participants will be debriefed and advised against using e-cigarettes.

Evaluating New Nicotine Standards for Cigarettes – Renewal

This research study will examine the impact of reducing nicotine in cigarettes in the context of alternative tobacco product availability. The study includes three projects. Project 1 is a 12-week clinical trial that examines the use of very low nicotine content (VLNC) vs. normal nicotine content (NNC) cigarettes when 700 adult smokers are given vouchers to exchange for cigarettes in an experimental marketplace that contains a wide range of non-combusted products. Project 2 is a seven-week clinical trial comparing VLNC and NNC cigarettes when 480 adult smokers have access to e-cigarettes that vary in nicotine concentration (high vs. low) and available flavors (tobacco only vs. tobacco and other flavors). Project 3 is a laboratory-based study that will assess the choice to smoke, vape, or abstain when 120 adolescent smokers (ages 18-24 are provided cigarettes with VLNC vs. NNC and e-cigarettes that vary in nicotine concentrations and flavors. Other study activities will include the analysis of biomarkers associated with exposure to nicotine and tobacco-related toxicants and the development of novel ways to analyze data.

E-Cigarettes: Formaldehyde DNA Adducts, Oxidative Damage, and Potential Toxicity and Carcinogenesis

Recent reports indicate that e-cigarettes may generate unacceptable levels of the human carcinogen formaldehyde, and preliminary data indicate that levels of urinary biomarkers of oxidative damage and inflammation are the same in e-cigarette users as in cigarette smokers. The goal of this study is to test whether e-cigarette use leads to formaldehyde-DNA adducts and elevated exposure to other carbonyls, and to similar levels of oxidative damage and inflammation as in smokers; the study will also assess toxicant and carcinogen exposure in e-cigarette users, smokers, and non-smokers. Specific aims are: (1) to quantify formaldehyde-DNA adducts in tissues of rats exposed to vapor generated from e-liquids containing propylene glycol; (2) to analyze samples from a prior study in which smokers stopped smoking for 12 weeks to determine the time course of decreases in formaldehyde-DNA adducts in leukocytes and 8-iso-PGF-2α and prostaglandin E2 metabolite (PGEM) in urine; and (3) to recruit 134 e-cigarette tank system users, 134 smokers, and 134 non-users of any e-cigarette or tobacco product and compare levels of (a) formaldehyde, diacetyl, and other carbonyl compounds in saliva (before and after puffing in the e-cigarette users and smokers), (b) formaldehyde-DNA adducts in oral cells and leukocytes, (c) 8-iso-PGF-2α and PGEM in urine, (d) C-reactive protein, the serum biomarker of inflammation, and (3) a panel of urinary toxicant and carcinogen biomarkers.

Impact of Prenatal Waterpipe Use on Infant Biomarkers and Neurodevelopment

Waterpipe tobacco (hookah, narghile) use has serious health risks similar to those associated with cigarette smoking. Waterpipe use is especially problematic among reproductive-age women because it increases the risk of obstetrical complications, low birth weight, and respiratory problems in newborns. However, although cigarette tobacco and nicotine are known to harm the developing brain, data regarding the effects of waterpipe tobacco use during pregnancy on infant toxic chemical exposure and neurodevelopmental outcomes is lacking. A prospective, observational, longitudinal study is investigating the impact of flavors and design features on waterpipe use patterns and toxic chemical exposure in pregnant and postpartum current waterpipe users; participants are being provided with information about the health risks of hookah and other tobacco use following assessments. In this supplement, investigators will analyze data from 115 infants of mothers participating in the longitudinal study. Study aims are: (1) to determine the impact of prenatal waterpipe tobacco use, flavors, and design features on biomarkers of infant nicotine and toxic chemical exposure (cotinine, volatile organic compounds [VOCs]), and (2) to determine the impact of prenatal waterpipe tobacco use, flavors, and design features on infant neurodevelopment. Investigators will collect infants’ urine and saliva to measure nicotine and markers of VOCs, respectively, and will assess neurodevelopment using the NICU Network Neurobehavioral Scale (NNNS), a standardized assessment designed to reveal deficits in substance-exposed infants.

Development of an In Vitro Porcine Buccal Model to Determine Permeability of Tobacco HPHCs

Measuring the absorption of harmful and potentially harmful constituents (HPHCs) in tobacco products through mouth exposure is important for understanding the toxic effects of these constituents. The goal of this study is to develop a measure of HPHC absorption (a “permeability constant”) that will allow investigators to predict how a given dose of a constituent absorbed through the mouth contributes to the relative risk of that constituent. In Phase 1 of the study, investigators will conduct a literature search on the physical and chemical properties of each constituent as well as their absorption through other membranes (i.e., skin, mucus membranes). In Phase 2, investigators will use an in vitro buccal (mouth) membrane absorption pig model to determine the permeability constants for five HPHCs found in smokeless tobacco: 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), nicotine, benzo[a]pyrene, crotonaldehyde, and arsenic. In Phase 3, investigators will use the model to evaluate HPHC properties in three to five different types of three smokeless tobacco products (moist snuff [including a reference product], dissolvables, and snus), and will measure the absorption percentage of each constituent. These results will be compared to the results generated in Phase 2. Study findings will provide new information about buccal absorption of HPHCs.

Creative Concept Testing to Prevent Youth ENDS Use in General & Hip Hop Audiences

FDA’s Center for Tobacco Products (CTP) will conduct a qualitative research study to inform the development of appropriate messaging to prevent electronic nicotine delivery system (ENDS) use among youth. Specifically, this study will use focus group discussions to explore the target audience’s reactions to various creative advertisement concepts and messaging probes intended to prevent youth ENDS use. Approximately 30 focus groups with up to nine participants each will be conducted in various locations across the U.S. with a total of up to 270 youth aged 12-17 who: (1) are at risk of initiating ENDS use; (2) have experimented with ENDS only (do not use or experiment with combustibles); or (3) have experimented with cigarettes and ENDS (dual experimenters). Additionally, up to six of the 30 focus groups will have an added recruitment criterion for participants to self-report as part of the multicultural Hip-Hop peer crowd. Participants will be diverse in terms of race/ethnicity, gender, and geographical location. Findings will inform the development of future public education campaigns targeting youth and ENDS use.

Nicotine Education Project: Qualitative Study to Gain Insights from Adult Current and Former Smokers to Educate the General Public

In order to inform potential communications to the public, FDA’s Center for Tobacco Products (CTP) will conduct a qualitative research study consisting of up to 30 focus groups to gain insights around tobacco perceptions and nicotine addiction messaging. Specifically, researchers will explore the target audience’s thoughts about nicotine and tobacco products as well as potential regulatory actions. Approximately 30 focus groups with up to eight participants each will be conducted in various locations across the U.S. with a total sample of up to 240 adults ages 19-54 who are: (1) current cigarette smokers, 2) former smokers who currently use a non-combustible tobacco product or nicotine replacement therapy, or (3) former smokers who do not currently use any nicotine products. Individuals will be diverse in terms of race/ethnicity, gender, and geographical location. Findings may inform future public education efforts related to nicotine.

Quantitative Study of Tobacco Facts Designed to Inform Youth Tobacco Prevention Messaging (TFR II)

The goal of this study is to evaluate scientific tobacco facts with regard to their applicability to special populations. Specifically, study results will inform the American Indian/American Native (AI/AN), Fresh Empire (multicultural youth) and The Real Cost: Smokeless (rural youth) campaigns. Youth reactions to the facts will be assessed on a range of reaction measures, including Perceived Argument Strength (PAS), trust, likelihood of sharing, understandability, likelihood of outcome, and desirability of outcome. Researchers will identify top-performing facts that can help inform the development of messages for FDA’s youth tobacco prevention campaigns. This study extends previous research that assessed the utility of cigarette and e-cigarette facts for use in future messaging with The Real Cost general market target audience (youth aged 13-17) who experimented with cigarette smoking or were susceptible to smoking.

2019 Electronic Nicotine Delivery Systems Formative Data Collection to Inform Experimenter and Established User Definitions

The goal of this study is to develop a working definition for youth ENDS experimentation as contrasted with established ENDS use. Researchers will conduct a study to explore youth use of electronic nicotine delivery systems (ENDS) to assess what measures of use or the user’s knowledge, attitudes and behaviors best differentiate experimenters from established users. Study subjects will include up to 1,600 youth aged 13-17 who have ever used an ENDS device such as an e-cigarette. Participants will be recruited online and will complete an online screening survey to determine eligibility. Qualified youth will participate in a survey that addresses the participant’s ENDS use and its social context; measures of tobacco product-related knowledge, attitudes, and behaviors; advertising and counter-marketing exposure; sensation-seeking; measures of other tobacco product use; and demographics. After analyzing the survey data, researchers will construct definitions of experimental and established ENDS use and test which definitions are effective at discriminating between experimental and established youth ENDS users using various measures, such as harm perceptions.

HPHC Level Monitoring of Tobacco Products

The identities and quantities of harmful and potentially harmful constituents (HPHCs) in different tobacco products, including newly deemed tobacco products commercially available in 2016-2017, is critical information that can be used to protect the public health. This study involves analyzing 30 brands of each type of tobacco product (e.g., cigarettes, smokeless tobacco, roll-your-own tobacco, pipe tobacco, waterpipe tobacco, e-cigarettes) representing the top, middle, middle-low, and low quartiles of market share for each tobacco type in and around the Atlanta metropolitan area. Researchers will analyze 33 HPHCs using various methods, including high performance liquid chromatography-mass spectrometry (HPLC-MS). Data on moisture, pH, tar, and engineering parameters will also be collected on the different tobacco products. The project is expected to be performed in three six-month phases. Phase 1 will include testing cigarette filler, roll-your-own tobacco filler, pipe tobacco, waterpipe tobacco and smokeless tobacco. Phase 2 will include testing cigarette smoke under intense and non-intense smoking regimens. Phase 3 will include testing e-cigarette liquids and aerosols. Study findings will provide a better understanding of the constituent yields for 33 HPHCs across tobacco product types and may inform regulatory activities related to HPHCs.

Effect of Menthol on Pharmacokinetic Profiles of Nicotine and Tobacco Specific Nitrosamines (TSNAs) in Rats

Animal studies using various routes of administration have been performed to investigate the pharmacokinetics of harmful and potentially harmful constituents (HPHCs); however, more information on the effects of menthol on the pharmacokinetics of HPHCs would be useful. The objectives of this study are to investigate the pharmacokinetics of nicotine and tobacco-specific nitrosamines (TSNAs) in 60 Sprague Dawley rats exposed to cigarette smoke, and to evaluate the effects of menthol on those pharmacokinetic profiles. Nicotine and TSNAs will be measured in blood, urine and tissue collected from the respiratory tract. The analyses will involve thorough evaluation of the pharmacokinetics of nicotine and TSNAs in rats exposed to low or high doses of cigarette smoke in the presence or absence of menthol.

Evaluation of the FDAs Public Education Campaign on Teen Tobacco (ExPECTT II)

To assess the effectiveness of the FDA’s efforts to reduce or prevent tobacco use by youth, researchers will conduct an evaluation of The Real Cost public education campaign targeting youth aged 12-17 years who are at risk for smoking cigarettes and e-cigarettes. The specific aims of the study are to gauge campaign awareness and examine the statistical relationships between exposure to the campaigns and changes in outcome variables of interest, which include changes in beliefs and attitudes regarding cigarette smoking and e-cigarette use. Data are being collected through in-person and online surveys of adults and youth in the United States. Approximately 6,000 at-risk youth and their parents will complete questionnaires at four time points (baseline and three follow-up surveys) at eight-month intervals. The results of the study will inform the development of this and future youth-oriented tobacco education campaigns.

Point of Sale Evaluation Intervention Evaluation (POSITEv)

The Center for Tobacco Products (CTP) launched a public education campaign, “Every Try Counts,” aimed at encouraging adult cigarette smokers to quit through messages of support that underscore the health benefits of quitting. The “Every Try Counts” campaign targets smokers aged 25-54 who have attempted to quit smoking in the last year but were unsuccessful. The campaign features motivational, positive messages that are displayed in and around gas stations or convenience stores – retail locations that typically feature cigarette advertisements and where smokers face multiple triggers. The campaign is being evaluated through a multi-year outcome evaluation study to determine the campaign’s effectiveness in affecting targeted tobacco-related knowledge, attitudes and beliefs, and changes in motivation to quit smoking among the target audience. The longitudinal study will follow a group of approximately 2500 individuals across up to four rounds of data collection conducted at approximately seven-month intervals. Data will be collected in person and online in 15 campaign-targeted media markets and 15 control markets across the U.S. Results from this study will be used to improve the current campaign and inform the development of future adult cessation public education initiatives.

Cigarette Packaging: Design, Cognition, and Consumer Choices

As part of its regulation of tobacco products, the Food and Drug Administration (FDA) can assess tobacco product packaging and labeling. Additional scientific evidence regarding what types of pack labeling changes matter to perceptions of “newness” would be informative. Study aims are: (1) to determine how adult smokers perceive cigarette product newness and identify design characteristics related to perceptions of newness; (2) to determine which cigarette pack design characteristics, when changed, are most important to adult smokers’ perception of product newness; and (3) to link changes in pack design identified in Aim 2 to adult smokers’ perceptions of taste, quality, and harm. Researchers will first investigate smoker perceptions of cigarette packaging changes by conducting five online focus groups including 6-8 adult smokers each; two groups will be diverse groups of low-income smokers, two will be diverse groups of LGBT smokers, and one will include diverse smokers in the general population. Researchers will then use focus group findings to inform two online surveys conducted with separate groups of 250 adult smokers each. The first experiment will assess which changes to pack labeling identified by the focus groups are most associated with the product being perceived as a new, distinct product. The second experiment will assess the influence of these labeling changes on the thoughts and feelings that drive smoker behavior. In these experiments, one-third of the subjects will be lower-income and one-third will be LGBT.

Perceptions, Initiation, and Use of E-cigarettes among Middle School Students: A New Generation of Tobacco Users?

E-cigarette use is growing among youth. Additional scientific knowledge regarding why e-cigarettes appeal to youth, the effects of e-cigarette use, and how e-cigarette marketing influences adolescents’ beliefs, intentions, and willingness to use these products would be useful. The goal of this study is to generate scientific data on e-cigarette marketing impact, access to products, and initiation and use among youth. Study aims are: (1) to examine the prevalence of lifetime e-cigarette use and current use patterns among 1,150 middle school students (ages 11-14; half Hispanic) across a school year; (2) to assess concurrent and prospective factors related to e-cigarette initiation and use, including perceptions of risk, social images of users, motives for using, intentions and willingness to use, access to products, and exposure to marketing; and (3) to explore associations between e-cigarette initiation and poly-use or willingness and intentions to use other tobacco products, as well as nicotine dependence symptoms resulting from e-cigarette use. Researchers will conduct two school-based surveys across a school year (Fall and Spring) in two middle schools. Based on information obtained in the school surveys, researchers will select 60 e-cigarette users for in-depth interviews in order to gather additional information on the contexts surrounding e-cigarette use, to obtain sequential details of co-use with other tobacco products, and to delve more deeply into the appeal and motivations to use e-cigarettes. Study findings will contribute to the body of research on e-cigarettes and youth.

Comparing Graphic to Text-Only Warning Labels to Discourage Cigarillo Smoking by Young Adults

Significant knowledge gaps exist regarding how to effectively communicate the risks of cigarillo smoking. The goal of this study is to test the effectiveness of possible warning labels that communicate cigarillo smoking risks. Study aims are: (1) to develop graphic cigarillo warning labels that effectively communicate the risks of cigarillo smoking by pairing existing images with the six FDA-required text warnings; and (2) to compare the relative effectiveness of text-only versus graphic cigarillo warning labels to discourage cigarillo smoking by young adult cigarillo users and at-risk nonusers. In Year 1, researchers will convene four focus groups, each with 7-10 young adults (ages 18-29) who are current users of or at risk of using cigarillos; focus groups will inform the development of the graphic warning labels by choosing images that represent the six text warnings in FDA’s Final Deeming Rule, which extends the agency’s regulatory authority over a variety of tobacco products, including cigarillos. Subsequently, researchers will conduct an experiment using a nationally-representative panel of 660 young adult cigarillo users and at-risk nonusers to assess the relative effectiveness of text-only versus graphic warnings in discouraging them from cigarillo smoking.

The Effect of Nicotine Delivery Rate on Reinforcement

If e-cigarettes deliver nicotine at rates above a certain threshold, they can be addictive and potentially harmful, especially in nicotine-naïve users. In contrast, if the nicotine delivery rate of an e-cigarette falls below a critical threshold, it may have low addiction liability yet still provide sufficient nicotine to help smokers quit by reducing smoking urges and nicotine tobacco withdrawal symptoms. However, the critical rate of delivery that underlies the addictive effects of nicotine has yet to be empirically validated by controlled human studies. To close this knowledge gap, researchers will test nicotine reinforcement in 18 adult male and female smokers who will participate in a total of four experimental sessions involving different rates of nicotine administration. During experimental sessions, subjects will be given an intravenous (IV) nicotine infusion of either saline (as placebo) or 1 mg nicotine at rapid, moderate or slow infusion rates (nicotine at 0.24, 0.05 or 0.02 μg per kg body weight per second). The infusion conditions for each experimental session will be determined in a random order. Study aims are: (1) to establish a dose-effect curve for nicotine reinforcement as a function of nicotine delivery rate; (2) to establish a dose-effect curve for nicotine’s positive and negative subjective effects as a function of nicotine delivery rate; (3) to establish a dose-effect curve for nicotine’s ability to alleviate nicotine withdrawal symptoms in abstinent smokers as a function of nicotine delivery rate; and (4) to establish a dose-effect curve for nicotine’s acute cardiovascular health effects. Data from this project may help to establish benchmark values for nicotine’s threshold effects.

Analysis of Chemical Constituents and HPHCs in Waterpipe Tobacco, Charcoal, Wastewater

The goal of this study is to characterize and quantify chemical constituents in unheated waterpipe (WP) tobacco, unburned WP charcoal, heated WP tobacco, burned WP charcoal, and WP wastewater, specifically related to the use of quick light charcoal. Study aims are: (1) to conduct a lab analysis of ten different WP tobacco products, five different WP charcoal products, and WP wastewater; (2) to characterize and quantify the different chemical constituents and harmful and potentially harmful constituents (HPHCs) for both unheated and heated WP tobacco; (3) to characterize and quantify the different chemical constituents and HPHCs for both unburned and burned WP charcoal; (4) to understand the filtering effect of WP wastewater for WP tobacco and charcoal chemical constituents and HPHCs; and (5) to determine whether these constituents and HPHCs affect public health and/or the environment. Study findings will provide data about the constituents of WP tobacco, charcoal, and wastewater, and may provide new information about potential environmental harm.

In Vivo Biomarker that Identifies Waterpipe Smoking-Related Lung Health

Waterpipe smoking is increasing in the US, particularly among young adults. The goal of this study is to develop an in vivo respiratory tract epithelium-based assay sensitive to waterpipe smoke toxicity, in order to predict the impact of waterpipe smoking on lung health. Researchers will analyze data from a cohort young adults (ages 18-35) that includes 200 waterpipe-only smokers and 100 never smokers. Researchers will gather a wide variety of data from the participants, including: (1) responses to questionnaires that assess tobacco use, other exposures, lung health, and cough and sputum scores; (2) urine cotinine and blood carboxyhemoglobin levels; (3) full lung function tests; (4) chest imaging; and (5) the respiratory tract epithelial transcriptome (i.e., the set of all messenger RNA molecules in a population of cells) from small airway epithelium (SAE) and nasal epithelium. The study aims are: (1) to identify abnormalities in the SAE transcriptome; (2) to identify abnormalities in the nasal epithelial transcriptome; and (3) to determine whether these biologic abnormalities correlate with abnormalities in lung function, and if so, whether the nasal epithelial transcriptome can be a surrogate for the SAE transcriptome in predicting lung toxicity. This research may provide an in vivo biomarker that can be used in future studies to assess waterpipe smoking-associated risk to lung health.

Assessment of Inhalation Toxicity of Essential Oils and Flavors in Tobacco Products

Essential oils and flavors are complex chemicals that may have the potential to worsen the risks associated with tobacco product use. The inhalation toxicity of these ingredients is often poorly characterized. To better understand the potential respiratory toxicity of essential oils and flavors used in e-cigarettes, researchers will expose normal human bronchial epithelial cells to the aerosols of nine essential oils and nine flavors generated under conditions simulating typical e-cigarette use, with and without co-exposure to nicotine, to evaluate the dose-response of cell toxicity. The 18 essential oils and flavors are buchu leaf oil, cinnamon bark oil, cinnamon leaf oil, lavender oil, orange oil, peppermint oil, sage oil (Spanish), spearmint oil, yiang ylang oil, 4-(p-Hyrdoxyphenyl)-2-butanone, benzaldehyde, benzyl alcohol, piperonal, diacetyl, ethyl maltol, ethyl vanillin, eugenol, and licorice extract. In addition, researchers will investigate the impact of 10 of these ingredients on oxidative stress, cellular morphology, inflammatory biomarker expression, and potential gene toxicity. The ingredients in the tested aerosols will be characterized using analytical methods such as gas chromatography/mass spectrometry, liquid chromatography/mass spectrometry, and tandem mass spectrometry. This study will identify the respiratory toxicity associated with essential oils and flavors.

Investigation of the Effects of Electronic Cigarettes on Vascular Health

Although e-cigarettes do not produce smoke and users are not exposed to tar and carbon monoxide, they deliver nicotine, which is the primary addictive component of tobacco. Nicotine has been shown to promote atherosclerosis by generating systemic oxidative stress, which leads to various adverse cardiovascular effects (i.e., lipid peroxidation, atherosclerotic plaque formation, endothelial dysfunction, vascular endothelial cell damage). The goal of this study is to establish the acute and chronic effects of e-cigarette use on inflammation, systemic oxidative stress, and endothelial toxicity in 60 subjects (20 nonsmokers, 20 established e-cigarette users, and 20 cigarette smokers; ages 18-35). Study aims are: (1) to characterize the effects of chronic e-cigarette smoking on systemic oxidative stress; (2) to determine the acute effects of e-cigarette smoking on endothelial cell integrity; and (3) to identify the effects of chronic e-cigarette usage on endothelial function. To achieve Aim 1, researchers will measure markers of oxidative stress (plasma and urinary levels of F2-isoprostanes) in nonsmokers, chronic e-cigarette users, and cigarette smokers. To achieve Aim 2, researchers will measure levels of endothelial progenitor cells (which increase as a result of endothelial injury) in e-cigarette users and cigarette smokers immediately before and after using an e-cigarette or smoking a cigarette, and compare these levels to those in nonsmokers. To achieve Aim 3, researchers will compare brachial artery flow-mediated dilatation measurements, expression of NFkB (a marker of vascular inflammation), and reduction in eNOS (an enzyme that is essential for cardiovascular health) in e-cigarette users, cigarette smokers, and nonsmokers.

Effects of Cigar Flavors on Measures of Abuse Liability among Young Adults

The availability of cigar flavors, among other characteristics, has been linked to increased sales and consumption, with the largest increases among youth/young adults and certain racial/ethnic minorities. No studies exist quantifying the effect of cigar flavors on abuse liability (the potential for dependence and addiction). Researchers will examine the effect of four flavors of Black & Mild (B&M), the most popular cigar brand, on different measures of abuse liability. In this study, 25 young adults (ages 18-25 years) who are current cigarette smokers but inexperienced cigar smokers (≤5 times) will complete five smoking sessions that differ by product smoked: own brand cigarette and B&M cigars in original, apple, cream, and wine flavor. Researchers will then evaluate three measures of abuse liability: (1) exposure to nicotine via saliva concentrations; (2) breakpoint from behavioral tasks where individuals choose between money or cigar puffs; and (3) subjective measures of cigar effects.

Analysis of Chemical Constituents in Cigarette Butt Leachate

A major environmental consequence of cigarette use is the disposal of discarded cigarette filters: each year, an estimated 4.5 trillion cigarette butts (1.69 billion pounds of cigarette butts) are thrown away worldwide. The National Environmental Policy Act requires an environmental impact analysis with human health impact scenarios for federal actions such as tobacco product marketing authorizations; thus, more information about the identities and amounts of constituents that leach from cigarette butts would be useful. Investigators will conduct a preliminary study to identify leachable constituents, including harmful and potentially harmful constituents (HPHCs), from cigarette butts. The objectives of this study are (1) to conduct laboratory analyses of three replicates from a single cigarette butt leachate; and (2) to characterize and quantify the different chemical constituents and HPHCs for the leachate. This study will provide new information about the leachable constituents in cigarette butts.

Examine the Impact of Ontario’s Bans on Flavored and Menthol Tobacco Products on Consumer and Industry Behavior in the Tobacco Retail Environment

In 2015, Ontario, Canada enacted the Making Healthier Choices Act, which banned flavored and menthol tobacco products, including e-cigarettes. The goal of this study is to evaluate the impact of that law on consumer purchase behavior and retail marketing. Study activities will primarily entail analyses of secondary data such as enforcement agency records, retail sales (i.e., scanner data), and tobacco manufacturer data on sales to wholesalers. An in-store purchase study to explore product availability will also be conducted. Findings will provide evidence on the implementation, effectiveness, impact, and any potential unintended consequences of Ontario’s Making Healthier Choices Act of 2015, which may inform FDA’s tobacco regulatory activities.

Intentions, Perceptions, Patterns, and Toxicant Exposure

Waterpipe smoking is a growing trend among young adults. A potential reason for the appeal of waterpipe tobacco is that it is nearly always flavored with sweeteners and additional fruit, candy, savory and dessert flavorings. The goal of this study is to investigate the impact of waterpipe tobacco flavors on waterpipe initiation, smoking behaviors, abuse liability, and exposure to tobacco-related toxicants. Study aims are: (1) to understand how flavorings impact waterpipe initiation, smoking behaviors, abuse liability, and exposure to tobacco-related toxicants; and (2) to understand whether level of waterpipe dependence influences the impact of waterpipe tobacco flavoring on smoking behaviors, intentions for continued use, abuse liability, and exposure to tobacco-related toxicants. Sixty current waterpipe smokers (ages 18-50; 30 rated “low” and 30 rated “high” on the Lebanese Waterpipe Dependence Scale) will all complete four waterpipe smoking sessions using four different tobacco flavors (i.e., preferred flavor/sweetened, preferred flavor/very low sweetened, unflavored/sweetened, unflavored/very low sweetened). Sessions will be preceded by 12 hours of tobacco/nicotine abstinence and separated by 48 hours, and waterpipe tobacco nicotine levels will be held constant across sessions. Researchers will collect measures of smoking behavior (puff topography), acute toxicant exposure (carbon monoxide boost and plasma nicotine), and self-report measures of abuse liability, intentions for continued use, and importance of flavors in using waterpipe. Findings will indicate whether flavorings influence users use behavior, intention to use, perceptions and subjective effects, and exposure to tobacco-related toxicants.

Comparative Pharmacokinetics and in Vivo Genetic Toxicology of the Tobacco Specific Nitrosamine NNN in Rats

A study that compares the pharmacokinetic effects of N-nitrosonornicotine (NNN), a carcinogenic tobacco specific nitrosamine (TSNA), by different administration routes would be informative. The purpose of this study is to compare the pharmacokinetics of NNN via three routes of administration (inhalation, oral, and intravenous) in order to understand NNN’s in vivo genotoxic effects. Investigators will expose six groups of rats (15 per group) to different NNN concentrations (low, medium, and high doses) via nose only inhalation (one hour exposure), intravenous injection, or oral gavage. Blood and urine samples will be collected over 48 hours and analyzed for NNN and its metabolites (R,S)-nornicotine and N´-nitrosonornicotine-1-N-oxide. Investigators will evaluate pharmacokinetic parameters including observed maximum serum concentration (Cmax), the time at which Cmax is observed (Tmax), apparent volume of distribution and clearance, area under the curve (AUC: last and infinity), elimination rate constant and its corresponding half-life, renal clearance, urinary excretion, and relative bioavailability. At 24 or 48 hour time points, investigators will analyze tissues for genotoxic endpoints using the Comet assay, micronucleus assay, and DNA adduct formation. Study findings may inform the development of pharmacokinetic models for NNN.

Development of a Standard Guideline Protocol for Rodent Tobacco Smoke Inhalation Studies

This study will measure the dose of cigarette smoke that represents the maximum tolerated dose (MTD), dose limiting toxicity, NOAEL (no observable effect level), and LOAEL (lowest observable effect level), as well as smoke’s effects on clinical symptoms and tissue changes at these levels. Researchers will expose groups of 10 male and female rats for 14 days to increasing amounts of smoke from the leading brand of cigarette until the MTD is reached. Next, researchers will expose control, low, mid- and high-dose exposure groups of 10 male and female rats each to commercial cigarette smoke generated under the ISO or Canadian intense regimen for 13 weeks at the MTD, the NOAEL or LOAEL, and an intermediate dosage. Researchers will measure clinical, blood, chemistry, toxicological, and respiratory effects. This study will serve as a guideline study against which other previously-published studies can be compared in the future and will provide new data about tobacco smoke toxicity in rats.

Informing Tobacco Regulatory Policy through Laboratory Assessment of Appeal and Demand for Flavored Tobacco Products among Young Adults

Young adults are particularly susceptible to the use of flavored tobacco products; additional research could help clarify the specific reasons underlying their appeal. The goal of this study is to develop new methods for quantifying flavored tobacco product appeal. Study aims are: (1) to validate indices of implicit (below conscious awareness) appeal across flavored and non-flavored products; (2) to examine differences in implicit appeal for flavored and non-flavored products in both susceptible (never) and current tobacco users, controlling for factors related to tobacco use (e.g., social influences, harm perceptions); and (3) to examine the impact of baseline implicit flavored product appeal on changes in flavored/non-flavored harm perceptions, intentions and curiosity to use, and tobacco use. Researchers will recruit 60 young adult current tobacco users and 60 susceptible never users (ages 18-24) and measure baseline implicit appeal for flavored and non-flavored tobacco products. Then, using monthly web-based assessments, researchers will evaluate the impact of appeal on changes in tobacco use behavior and attitudes over six months. Implicit appeal will be assessed via two laboratory tasks: (1) an Implicit Association Task that measures the speed with which participants accurately pair pictures of flavored versus non-flavored products with words related to “attractive” or “unattractive,” and (2) a behavioral economic purchase task designed to assess demand for flavored versus non-flavored products under escalating price conditions. The goal is to determine whether implicit flavored product appeal is higher than non-flavored product appeal, especially among susceptible never users, and whether flavored product appeal negatively influences tobacco use outcomes and attitudes.

PATH Questionnaire Reliability and Validity Study

The Population Assessment of Tobacco and Health (PATH) Study is a national longitudinal study of tobacco use and health that is following approximately 46,000 U.S. household residents ages 12 and older. The goal of this study is to evaluate the reliability and validity of the PATH Study adult and youth Round Four assessment instruments. Researchers will interview 875 PATH Study respondents who represent a subsample of the PATH Study sample areas. Respondents will be interviewed twice, with the re-interview completed within 10-17 days after the initial interview. For a subset of the items where discrepancies are found, the questionnaire will include probes designed to shed light on the nature of the discrepancy. At the end of the re-interview, the interviewer will photograph the products used by the participant so that they can be compared to the brands self-reported in the questionnaire. To assess the validity of answers to key items on tobacco use, researchers will analyze saliva specimens for biomarkers of exposure. Researchers will conduct additional analyses to identify person-level variables associated with different levels of reliability, identify question characteristics that affect answer reliability, and examine different methods for estimating reliability. Study findings will be incorporated in new tools to predict the reliability of study questions in order to advance measurement practices in future studies.

Impact of Ontario Menthol Cigarette Ban

In May 2015, Ontario, Canada passed legislation banning menthol cigarettes as of January 2017. This legislation presents an opportunity to understand the impacts of a menthol ban on individual and industry behavior. To goal of this study supplement is to use large-scale survey and mixed quantitative/qualitative methods to evaluate the effects of Ontario’s menthol ban on smoker and industry behavior. Study aims are: (1) to understand user behavior changes subsequent to a menthol ban by quantifying changes in tobacco use among recent menthol smokers (defined as having smoked a menthol cigarette in the past year), and (2) to characterize industry behavior changes subsequent to the menthol ban by analyzing pack and advertising signs and symbols. The project involves three studies. The first involves telephone surveys of cigarette smokers; the surveys include questions about tobacco use behaviors, demographics, and knowledge of and support for a menthol cigarette ban in Ontario. A total of 1,041 smokers (ages 16 and older) completed a baseline survey before the menthol cigarette ban went into effect; 27% reported smoking a menthol cigarette in the past year. These menthol cigarette smokers will complete two additional follow-up surveys to track changes over time following the ban implementation. The second study involves visiting retail stores in Ontario to identify menthol cigarette availability and attempting to purchase menthol cigarettes before and after the menthol cigarette ban; packaging will be analyzed for content and the cigarettes themselves will be analyzed for the presence and amount of menthol. A final study involves an approach called concept mapping. In this study, 50-100 menthol smokers from the first study will identify specific behavior changes they have made and other ways the menthol cigarette ban has affected them. This project will be the first rigorous evaluation of a real-world ban on menthol flavored tobacco in a large market. Results will reveal how recent menthol smokers respond to the ban and how the tobacco industry adapts to it, and may inform regulatory activities related to menthol.

The Effects of Flavors on Nicotine PK/PD and Use Topography in E-Cigarette Users

Clinical studies investigating the effects of e-liquid flavors on nicotine exposure, pharmacokinetics (the body’s effects on the absorption, distribution, metabolism, and elimination of nicotine), pharmacodynamics (the effects of nicotine on the body), and use behaviors may increase knowledge regarding the health effects of e-cigarettes. The goal of this study is to investigate the effects of e-liquid flavors on topography (use behaviors) and nicotine pharmacokinetics and pharmacodynamics, and to begin to establish the effects of flavors on biomarkers of exposure in experienced e-cigarette users. Researchers will conduct a clinical study where experienced adult e-cigarette users will complete four sessions where they will use e-liquids of different flavors (e.g., tobacco, menthol, fruit) in nicotine and nicotine-free conditions. During these sessions, researchers will collect blood and urine samples, vital signs, topography, abuse liability measures, subjective effects, and other self-report measures. The study will yield information on the effects of e-liquid flavors on nicotine pharmacokinetics and pharmacodynamics, biomarkers of exposure, and topography, and may provide useful information on the impact of these tobacco products on public health.

Dose Effects of Nicotine: Behavioral Economics of Cigarette Abuse Liability

Reduced nicotine cigarettes may result in decreased nicotine intake and dependence. However, the addictive effects and abuse liability of reduced-nicotine cigarettes are less well understood. The goal of this study is to determine the abuse liability of reduced-nicotine cigarettes compared to standard full-nicotine cigarettes. Study aims are: (1) to determine if six weeks of exposure to reduced nicotine cigarettes reduces demand for reduced nicotine cigarettes; (2) to determine if six weeks of exposure to reduced nicotine cigarettes reduces the abuse liability of full-nicotine cigarettes; (3) to determine the degree to which various levels of nicotine in fixed-price reduced-nicotine cigarettes may substitute for full-nicotine cigarettes when full-nicotine cigarette price increases, both before and after six weeks of exposure to reduced-nicotine cigarettes; (4) to determine the “addictiveness threshold” by examining the above aims with varying levels of reduced nicotine cigarettes across participants; and (5) to determine the relationship between behavioral economic assessments and traditional subject-rated abuse liability assessment (i.e., ratings of “liking”). The study will include 100 non-treatment seeking dependent adult smokers (50 men, 50 women) who will smoke either full nicotine cigarettes (15.8 mg nicotine/g tobacco) or reduced nicotine cigarettes (5.2, 2.4, or 1.3 mg/g) at home for six weeks. Researchers will assess abuse liability using two measures of demand — lower demand intensity and increased demand elasticity — as well as other demand measures and subjective ratings of “liking,” and will evaluate the degree to which reduced-nicotine cigarettes may substitute for full-nicotine cigarettes.

Vapor and Particulate Phase Smoke Components and Cardiovascular Dysfunction

The health risks of waterpipe (hookah) smoking include harmful cardiovascular and pulmonary effects. The goals of this study are: (1) to clarify the role of toxic constituents in waterpipe smoke in the development of cardiopulmonary diseases, and (2) to evaluate the role of inflammation and oxidative stress. After describing the chemical composition of waterpipe smoke, researchers will measure changes in respiration, electrocardiographic patterns, and cardiac function during and after acute and chronic waterpipe smoke exposure in mice that are genetically susceptible to atherosclerosis using implanted telemetry devices. Study aims are: (1) to use state-of-the-art analytical methods to identify potentially harmful constituents in waterpipe smoke; (2) to assess the redox and electrophilic properties of gas- and particle-phase components present in waterpipe smoke extracts using in vitro systems that explore various mechanisms of action; and (3) to assess the cardiopulmonary toxicity of waterpipe smoke in mice experiencing acute and chronic exposures in order to assess the impact of inflammation and oxidative stress on the lungs, brain, and cardiovascular system. This study will be among the first to evaluate the cardiopulmonary toxicity of waterpipe smoke by in vitro and in vivo assays.

Adolescent ENDS Use, Nicotine Metabolism and Toxicant Exposure

Use of electronic nicotine delivery systems (ENDS), such as e-cigarettes, is increasing among adolescents. The goal of this study is to investigate e-cigarette toxicant levels and the influence of nicotine metabolism rate on use behaviors and nicotine dependence in adolescents. Study aims are: (1) to investigate the level of toxicants including propylene oxide, acrolein, ethylene oxide, benzene, acrylamide, formaldehyde, and 1,3, butadiene found in adolescent ENDS-only users; and (2) to examine the association between nicotine metabolism rate (measured by the salivary 3’hydroxycotinine/cotinine ratio) and the frequency of ENDS use and reported dependence in adolescent ENDS-only users. Researchers will enroll 180 adolescent ENDS-only users (aged 13-17 years) and a control group of 20 similarly-aged non-smokers/non-ENDS users. Researchers will analyze urine to determine toxicant levels and saliva to determine the nicotine metabolism rate. ENDS behavior questionnaires and nicotine dependence scales will be administered.

Assessing Toxicity of Waterpipe Tobacco Smoking in Laboratory and Naturalistic Settings

Waterpipe users are exposed to toxicants classified by FDA as harmful and potentially harmful constituents (HPHCs). As part of this study, researchers will conduct two projects. Project 1 is a machine-smoking study designed to determine the effects of different use behaviors (topography) on the toxicity of waterpipe tobacco smoke inhaled by users. Researchers will use a machine to “smoke” a popular U.S. manufactured waterpipe tobacco (Starbuzz) using two variables — quick-light charcoal vs. charcoal-free electrically heated waterpipe head, and room temperature water vs. adding ice cubes in the waterpipe jar – to create four waterpipe configurations. They will then quantify and compare levels of mainstream carbon monoxide (CO), nicotine, select volatile and semi-volatile organic compounds including furan. Project 2 is a real-world study of the effects of these smoking practices on biomarkers of toxicants and carcinogens. Researchers will recruit a sample of 50 adult male and female exclusive waterpipe smokers and a control sample of 25 adult male and female non-smokers. Waterpipe smokers will smoke one waterpipe tobacco head (10g) of Starbuzz during three separate sessions: Session 1: smoking waterpipe tobacco using quick-light charcoal and room temperature water in the waterpipe jar; Session 2: smoking waterpipe tobacco using quick-light charcoal and adding ice cubes to the water in the waterpipe jar; and Session 3: smoking waterpipe tobacco without charcoal using a charcoal-free electrically-heated waterpipe head and room temperature water in the waterpipe jar. Researchers will collect the following data from participants: (1) tobacco use history; (2) a four-week tobacco exposure diary; (3) a waterpipe use session form; (4) CO exposure (measured using a Micro+ Smokerlyzer® CO monitor) and (5) six first-morning urine samples, in order to measure nicotine metabolites and other biomarkers of tobacco exposure.

Nicotine Reinforcement and Aversion in Young Adult Light Smokers

The critical threshold for nicotine reinforcement that underlies the addictive effects of nicotine has yet to be empirically validated by controlled human studies. The goal of this study is to use a novel intravenous (IV) nicotine self-administration model to estimate threshold reinforcing doses of nicotine and to generate dose-effect curves for low doses of nicotine in smokers. Study aims are: (1) to assess the threshold reinforcing dose and dose-effect curve for IV nicotine self-administration at low doses in young adult light and intermittent smokers (“chippers”); and (2) to assess the threshold and dose-effect curve for the positive and negative/aversive subjective effects of IV nicotine at low doses and its relationship to nicotine reinforcement. Researchers will enroll 72 young adult (ages 18-30) male and female light and intermittent smokers who show few or no signs of addiction. Smo