Category: Policy

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. Smokers will participate in five experimental sessions. In each session, they will first be exposed to the assigned nicotine dose and the placebo (saline) dose followed by the opportunity to choose between nicotine and placebo administrations.

Targeted Tobacco Regulatory Science: Nicotine Dose Effects in Animal Models of Smoking Initiation in Vulnerable Adolescent Subpopulations

Adolescents with depression and/or Attention Deficit Hyperactivity Disorder (ADHD) have a higher incidence of smoking, start smoking at a younger age, exhibit a faster progression to daily smoking and dependence, and are less successful at quitting than adolescents without depression and/or ADHD. The goal of this study is to determine whether depression and ADHD predispose adolescents to nicotine addiction by lowering their nicotine reinforcement threshold. Experiments involving smoking initiation in adolescents cannot be accomplished in human studies, but can be addressed with animal models. Study aims are to test the hypothesis that the nicotine reinforcement threshold is lower in adolescent rat models of depression (Aim 1) and ADHD (Aim 2) compared to control animals. Researchers will determine the threshold-reinforcing nicotine dose for acquisition of nicotine self-administration, and will assess self-administration persistence during increases in the “price” of nicotine (i.e., difficulty reducing intake), nicotine pharmacokinetics (how quickly the body eliminates nicotine), and sex differences. These data will provide insight into the relative risk of nicotine reinforcement in adolescents, and how the reinforcement threshold is modified by depression and ADHD.

Understanding Tobacco Flavor Effects on Waterpipe Smokers’ Experiences and Exposures

Waterpipe tobacco smoking is increasing rapidly in the U.S., particularly among youth and young adults. Evidence suggests that waterpipe smoking can lead to addiction, cigarette smoking, and known smoking-related diseases including cancer, cardiovascular disease and adverse pregnancy outcomes. The goal of this study is to evaluate the impact of flavorings on nicotine delivery, toxicant exposure, dependence, and smoking behavior. This will be evaluated in a clinical laboratory study including beginning as well as established waterpipe smokers. The study will compare how smoking unflavored waterpipe tobacco compares to preferred flavored brand in terms of smokers’ exposure to nicotine, puffing behaviors, subjective measures of satisfaction, and suppression of withdrawal and craving. Researchers will recruit two groups of waterpipe smokers aged 18-30) based on their use frequency: 72 low frequency smokers (beginners) and 72 high frequency (experienced) smokers. All subjects will participate in two waterpipe smoking sessions that differ by flavor (preferred flavor; unflavored). Study aims are: (1) to examine the influence of flavor manipulation on subjective/dependence responses among beginning and experienced waterpipe smokers: (2) to examine the influence of flavor manipulation on nicotine delivery among beginning and experienced waterpipe smokers; and (3) to examine the effect of flavor on smoking behavior (puff topography) and toxicant exposure among beginning and experienced waterpipe smokers.

Reactions to Reduced Nicotine Cigarettes in Young Adult Low-Frequency Smokers

Evidence suggests that reducing nicotine content in cigarettes reduces smoking behavior and toxicant exposure among dependent adult daily smokers, but more research is needed regarding the effects of nicotine reduction on experimentation with cigarettes among adolescents and young adults at risk for progression to regular use and dependence. The goal of this study is to evaluate reactions to, and choices to self-administer, cigarette smoke with varying nicotine content among 90 low-frequency (i.e., smoke less than 15 days per month), non-dependent adolescent/young adult smokers (ages 18-25 years). Study aims are: (1) to evaluate the effects of nicotine content on subjective reactions to fixed doses of cigarette smoke at three nicotine content levels in adolescent/young adult, low-frequency smokers; (2) to evaluate choice of study cigarette to self-administer following sampling the three nicotine content cigarettes; and (3) to evaluate moderators of reactions to, and choices for, cigarette smoke with varying nicotine content. Participants will undergo three sessions in which their reactions to fixed doses of smoke from investigational cigarettes with three different nicotine contents (15.8, 2.5, and 0.4 mg/gram of tobacco) will be measured. Following the third fixed-dose session, participants will return to the lab to choose one of the cigarettes to self-administer. This will provide an evaluation of the amount of nicotine in cigarette smoke that produces reactions and choices associated with progression from initial smoking to nicotine dependence.

Topography, Constituents, and Toxicity of Waterpipe Tobacco Smoke Under Realistic Conditions

The goal of this study is to measure waterpipe smoke emissions and levels of inhaled constituents associated with different smoking topographies (use behaviors) and assess effects on pulmonary toxicity. Study aims are: (1) to compare waterpipe smoking topography and toxicity based on real-life use; (2) to identify harmful and potentially harmful constituents (HPHCs) inhaled by users under realistic use conditions based on waterpipe smoking topography; and (3) to determine the impact of waterpipe smoke on pulmonary and gene toxicity. Researchers will measure waterpipe and conventional cigarette smoking topographies (including frequency and exposure duration) in 25 waterpipe smokers, 25 cigarette smokers, and 25 dual users aged 21-65 who will use a wireless personal use monitor for three weeks; these participants and 25 nonsmokers will provide urine and blood samples to allow researchers to compare changes in biological indicators of oxidative stress and inflammatory responses. Next, waterpipe smoke emissions will be machine-generated using the subjects’ puffing topographies, and researchers will measure the chemical constituents in inhaled emissions. Finally, investigators will compare the effect of waterpipe tobacco and cigarette smoke exposures on pulmonary toxic responses (e.g., oxidative stress, inflammatory markers including lipid mediators and C-reactive protein) and gene toxicity (DNA damage/repair) in mice. Findings may inform regulatory activities related to waterpipe use.

Abuse Liability of Reduced Nicotine Content Cigarettes in the Context of Concurrent E-Cigarette Use

Information regarding the impact of reducing the nicotine content of cigarettes on tobacco product use behavior would be helpful in understanding the potential consequences of possible nicotine regulation. Researchers will randomize 320 smokers (both heavy, long-time smokers and lighter, younger smokers) to switch from their usual brands of cigarettes to research cigarettes with similar tar yields but five different nicotine contents. All participants will have access to concurrent use of e-cigarettes during the 12-week exposure period. Study aims are: (1) to assess the effects of cigarette nicotine content on abuse liability among smokers who also use e-cigarettes; (2) to measure nicotine discrimination thresholds and how they are affected by exposure to reduced nicotine content cigarettes; and (3) to determine the relationship between abuse liability of low nicotine cigarettes and extent of e-cigarette use. Researchers will assess the effects of cigarette nicotine content on measures of abuse liability including daily cigarette consumption, smoking reward and measures of dependence such as nicotine withdrawal symptoms. In laboratory sessions, researchers will measure nicotine thresholds for detecting and recognizing the rewarding effects of smoking.

Impact of Flavors and Design Features on Patterns of Waterpipe Use and Toxicity in Pregnant Mothers

Studies have reported an association between waterpipe tobacco use during pregnancy and increased risks of infertility, obstetrical complications, low birth weight, and respiratory problems. Sweetened flavored waterpipe tobacco and novel design features have contributed to the growth in waterpipe use. However, data are lacking regarding rates and patterns of waterpipe tobacco use, the impact of flavors and design features on use patterns, and biomarkers of nicotine and toxicant exposure in pregnant women in the U.S. The goal of this prospective longitudinal study is to investigate the impact of flavors and design features on use patterns, dependence, and biomarkers of toxicant exposure in 100 pregnant current waterpipe users. Study participants will complete detailed interviews regarding (a) use, perceptions, and preferences for waterpipe flavors and design features, and (b) patterns of waterpipe and dual/poly waterpipe tobacco use and dependence at three assessment points (first and third trimesters, and three months postpartum). Design features will be investigated through personal photographs of waterpipes and waterpipe tobacco use (e.g., owned waterpipes, waterpipe smoking in bar settings) throughout pregnancy and postpartum. Urine, breath, and saliva samples will be collected to assess maternal/fetal exposure to nicotine, carbon monoxide, and state-of-the-art markers of volatile organic compounds. Participants will be provided with information about the health risks of waterpipe and other tobacco use following assessments.

Abuse Liability of Reduced Nicotine Content Cigarettes within a Complex Tobacco Marketplace

Research regarding how reduced nicotine cigarettes are valued by smokers may provide information about their abuse liability. The goal of this study is to use behavioral economic methods to examine consumption of reduced-nicotine cigarettes within the context of the larger tobacco marketplace. Study aims are: (1) to examine the effect of nicotine concentration in tobacco and resulting plasma nicotine on laboratory behavioral economic measures of demand intensity and elasticity, and (2) to assess behavioral economic measures of demand intensity and elasticity of cigarettes and substitution by dose in the Experimental Tobacco Marketplace under four conditions that mimic two different potential regulatory environments and two control conditions. To achieve Aim 1, researchers will ask daily cigarette smokers to consume, on separate sessions, controlled puffs of a cigarette containing a blinded concentration of nicotine and then complete a cigarette purchase task while plasma nicotine is measured. To achieve Aim 2, researchers will use the Experimental Tobacco Marketplace, a method that allows experimental price manipulation while simulating real-world markets featuring different tobacco products; two different regulatory environments will be studied. Experiments will determine how valued reduced-nicotine cigarettes are, whether reduced-nicotine cigarettes are preferred and substitute for conventional cigarettes in a complex tobacco marketplace, and whether the introduction of reduced-nicotine cigarettes into the marketplace influences the consumption of other combustible and non-combustible nicotine products.

Evaluating Concomitant Use of Very Low Nicotine Content Cigarettes and E-cigarettes among Daily and Non-Daily Smokers on Abuse Liability

It is unknown whether the potential of very low nicotine content cigarettes (VLNCCs) to reduce abuse liability might be offset by the concurrent use of e-cigarettes. The goal of this study is to model abuse liability in a market in which VLNCCs and e-cigarettes (an alternate source of nicotine) are both available. 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. Participants will smoke their usual brand during week 1 and will exclusively smoke VLNCCs during weeks 2-4. During weeks 5-7 and weeks 8-10, participants will be instructed to freely use any combination of VLNCCs and e-cigarettes with either high or low nicotine content (36 mg/ml or 8 mg/ml; three weeks each). The study will obtain 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. Study findings may provide additional information on the impact of reducing combustible cigarette nicotine to a non-reinforcing level in a dual product use environment.

Effect of Waterpipe Tobacco Ingredients on Human Puffing, Exposures and Appeal

Increases in waterpipe use may be due, in part, to the availability of sweet, fruit- and candy-flavored tobaccos that make inhaling tobacco smoke more appealing. Flavorings and high levels of sweet humectants produce harmful and potentially harmful constituents in the smoke, and are thought to contribute to the direct and indirect harm experienced by users. To define the effects of specific chemical content with respect to sweet perception and likability among users, researchers must use waterpipe tobacco that differs only in the variables of interest; however, there is no set of commercially-available tobacco brands for which this is true. In this study, researchers will manipulate commercial products to systematically investigate the effects of sweet humectant concentration and flavorings on the appeal, puffing behavior, and toxicity of waterpipe tobacco smoking. Study aims are: (1) to characterize the content of four waterpipe tobaccos (one brand prepared four different ways to vary flavoring, humectant, and sweetness levels); (2) to characterize the mainstream smoke generated from the four waterpipe tobaccos; (3) to determine how waterpipe tobacco content impacts puffing behaviors, perceived sweetness and appeal of waterpipe smoking; and (4) to determine HPHC and particle exposure ranges from the average puffing behaviors measured under Aim 3 for each tobacco preparation. Researchers will conduct mainstream smoke analyses and then conduct four laboratory smoking sessions with 40-48 adult waterpipe smokers (ages 18 and older) to collect data related to puffing topography and perceptions.

Harmful Constituents and Respiratory Effects of Waterpipe Smoke

The social culture of waterpipe use, the perception that waterpipe smoking is less harmful than cigarettes, and wide availability of flavored tobacco products influences waterpipe popularity among younger adults. The goal of this study is test whether different waterpipe products and puffing regimens generate unique profiles of harmful and potentially harmful constituents (HPHCs) that will yield a continuum of toxic health effects in in vivo and in vitro models. Study aims are: (1) to define the constituents of mainstream and secondhand waterpipe smoke using different puffing regimens and several different popular shisha products/flavors; (2) to conduct comparative in vitro and in vivo exposures to different waterpipe products and assess multiple effect endpoints of toxicity in lungs and in vitro airway epithelia; and (3) to identify biomarkers of exposure from studies in Aim 2 and examine human urine samples from individuals with recent mainstream/secondhand exposure to waterpipe smoke. Researchers will then use bioinformatics approaches to integrate human in vivo and in vitro data from the three study aims to develop an overall hazard index.

Impact of Waterpipe Configuration on the Size Distribution and Number Density of Smoke Particles and Targeted Chemical Analysis of Particle Profiles that Diminish Alveolar Cell Health

Both new and long-time waterpipe smokers have misconceptions regarding the filtration ability of the waterpipe’s bowl liquid and the toxicity of components drawn into the lungs. However, waterpipe tobacco smoke includes many of the same harmful components found in cigarette smoke, and is even more complex because it includes charcoal heat source combustion products and pyrolysis products from the waterpipe tobacco’s humectants and flavorants. Air quality research can provide important data about waterpipe smoke hazards. The goal of this study is to examine the physical and toxicological characteristics of waterpipe smoke particles that affect air quality. Because particulate formation is affected by waterpipe configuration, researchers will analyze the physical properties of particles generated when pipe height, heat source (charcoal vs. non-charcoal), tobacco, and hose length/material are varied (Study Aim 1). Researchers will also determine the relative cell toxicity of waterpipe tobacco smoke generated by different waterpipe configurations and smoking regimes (Study Aim 2). These investigations will use whole smoke (not re-suspended condensate or vapor) and lung cells grown and exposed to smoke at the air-liquid interface.

Tobacco Use Outcome Equalities and Tobacco Marketing Features

Certain tobacco marketing features (e.g., colors, descriptors, branding, marketing claims) may appeal to specific ethnic groups and thus may result in tobacco use outcome inequalities. The aims of this study supplement are: (1) to describe key features of tobacco marketing that could contribute to these inequalities, and (2) to identify the features associated with liking and recall of advertisements. Researchers will content code tobacco marketing images and show those images to an ethnically diverse sample of 2,000 youths (12-17 years old) and 2,000 young adults (18-24 years old) who will be recruited using Facebook and Instagram. To achieve Aim 1, tobacco ads from 2016 will be content coded for key marketing tactics. To achieve Aim 2, participants will take an online survey in which they will be shown a random sample of 20 ads and asked whether they recalled seeing the ad in the past 12 months and whether they liked the ad. Researchers will use these data to calculate “recalled” and “liked” ratings for each ad, and will compare features to the ad features coded in the content analysis. Ultimately, the marketing features identified through this project will be integrated into future experimental studies to assess how they affect consumers’ cognitive and affective responses. This work will allow the key features of the ads most recalled and most liked by different ethnic groups to be identified.

Biomarkers for Dependence and Menthol in ENDS

Chronic exposure to menthol changes the level of nicotinic acetylcholine receptors (nAChRs) in the brain, which may help to explain the observation that menthol smokers find it harder to quit. This study supplements a parent grant that established a biomarker for nicotine dependence in mice and then used that biomarker to study the impact of menthol on nAChRs. This supplemental study will develop and use a set of three live-cell assays suitable for assessing tobacco product additives such as menthol and electronic nicotine delivery system (ENDS) liquid flavorings. Supplemental study aims are: (1) to select human neuroblastoma cell lines expressing human nicotine-sensitive nAChRs; (2) to develop and standardize three assays for assessing the effects of menthol on nAChRs; and (3) to use the assays to assess whether chronic exposure to menthol isomers added to tobacco cigarettes and ENDS has specific effects on the brain.

The Effects of Modest Changes in Cigarette Menthol Content on Nicotine Pharmacology and Smoking Topography

Recent research on cigarettes and other tobacco products indicates that flavors, including menthol, may play an important role in user liking and sensation, and may directly or indirectly influence the pharmacology of nicotine and its associated abuse liability. In this study, researchers will investigate the impact of smoking cigarettes with four menthol concentrations on nicotine exposure, pharmacokinetics (the movement of nicotine in the body), metabolism, pharmacodynamics (the effects of nicotine on the body), and topography (use behavior). Forty-eight experienced adult (aged 18-65) menthol smokers will complete a screening visit and four clinical laboratory sessions where they will smoke one of four products: either a non-mentholated research 0.8 mg nicotine yield cigarette or the same research cigarettes that have been modified to achieve concentrations of low, medium, and high menthol levels (3, 6, and 12 mg, respectively) that bracket the menthol content of most commercially-available cigarettes. All laboratory sessions will include prescribed use and ad libitum use sessions. Researchers will measure the impact of menthol on smoking topography, nicotine pharmacokinetics, pharmacodynamics, and subjective assessments of abuse liability, risk perceptions, and product characteristics (e.g., strength, harshness). The study will provide a comprehensive assessment of menthol level on the acute effects of cigarette smoking, including effects on exposure, behavior and subjective effects.

ITO Chemical Analysis of Mainstream Smoke from Little Cigars, Cigarillos and Large Cigars to Determine Quantities of Carbonyls

Carbonyls (including acetaldehyde, acrolein, 2-butanone, crotonaldehyde, and formaldehyde) are strong, toxic irritants of the skin, eyes and nasal passage. Human exposure to these chemical constituents is introduced through tobacco smoke. The goal of this project is to conduct chemical analyses on little cigars, cigarillos, and large cigars to determine mainstream smoke quantities of acrolein (the main contributor to non-cancer respiratory effects from cigarette smoke) and other carbonyls (all of which have shown to cause cancer). Investigators will measure carbonyl quantities in a variety of little cigar (10), cigarillo (10) and large cigar (5) tobacco products currently marketed in the United States, under ISO and Canadian intense smoking regimens and using CORESTA recommended methods for carbonyl analysis.

Quantitative Study of Tobacco Facts Designed to Inform Youth Tobacco Prevention

The goal of this study is to assess the impact of different tobacco-related facts that may be used to inform messaging strategies used in FDA’s youth tobacco prevention campaigns. The study will include pre-test cognitive interviews followed by an online survey that will solicit opinions on a set of facts about a variety of tobacco products, including cigarettes, cigars, e-cigarettes, hookah (waterpipe), and smokeless tobacco; the online survey will ask respondents to rate approximately 10 randomly-selected tobacco-related facts and then answer questions about their knowledge, attitudes and beliefs about these facts. Pretest interviews will be conducted with 22 youth ages 13-17 in order to: (1) assess technical aspects and functionality of the survey instrument, and (2) identify areas of the survey that may be unclear or difficult to understand. Participants will complete the survey and will then be interviewed individually or with one or two other participants about the survey. The survey will be refined based on feedback, and then will be administered to approximately 1500 youth ages 13-17. The results of the survey will be used to inform messaging for future tobacco prevention campaigns.

Assessment of Tobacco Product Pharmacology and Behavior using Nonclinical Models

Nicotine is as the primary constituent in tobacco that promotes addiction; however, studies indicate that minor tobacco alkaloids contribute to the reinforcing effects of nicotine. Researchers will conduct behavioral studies in adult rats to compare the addictive potential of whole tobacco extracts from various tobacco products. A smoking machine will generate whole tobacco smoke or aerosol condensate from up to 15 commercially-available U.S. brands of each of the following four tobacco products (including flavored products): cigarettes, little cigars, e-cigarettes, and waterpipe tobacco. Researchers will analyze amounts of nicotine and minor tobacco alkaloids (nornicotine, acetaldehyde, anabasine, anatabine, myosmine, cotinine, harmane, and norharmane) in the different tobacco products. After analysis, researchers will select a representative brand for each tobacco product and generate an aqueous solution for use in rodent self-administration studies. Adult male rats (4 groups with 10 rats per group) will be trained in a self-administration model designed to compare the reinforcing effects of nicotine alone (in a control solution that contains none of the minor tobacco alkaloids) and the aqueous smoke or aerosol solutions generated from each of the four products. Study results will provide information on the levels and associated abuse liability of non-nicotine tobacco constituents in several brands of different tobacco products.

Chemistry and Design of Cigars and Related Products

Cigars are combusted tobacco products with filler, binder and wrapper all made from tobacco. Compared to cigarettes, less information exists on the chemistry of cigar filler and smoke. Cigars differ from cigarettes in tobacco type, tobacco processing and curing, product design, and manufacturing, all of which may cause them to have different chemical properties than cigarettes. The goal of this research project is to survey the chemical and physical characteristics of cigars of different types and compare them with cigarettes. Laboratory analyses will include the measurement of specific harmful and potentially harmful constituents (HPHCs) and other tobacco-related compounds in cigar tobacco filler, cigar smoke, cigarette tobacco filler, and cigarette smoke, using quantitative analytical methods and appropriate smoking regimens. Findings will help inform how cigars may be distinguished from cigarettes and whether they present different public health impact concerns.

Tobacco: Relationship between Reduced Nicotine Content and Reinforcement in Rats

Despite increasing awareness about the adverse health effects of smoking, adolescents continue to experiment with cigarettes and about two-thirds of them transition from occasional to daily smoking. The goal of this study is to determine whether positive and negative reinforcing properties of low-nicotine cigarettes are diminished compared to those of high-nicotine cigarettes in a rat model; the positive reinforcing effects of nicotine are critical for the initiation of smoking and the negative reinforcing effects of withdrawal prevent people from maintaining abstinence. Study aims are: (1) to determine if the nicotine content of tobacco affects the rewarding properties of smoke in adolescent rats; (2) to determine if exposure to tobacco smoke with various nicotine levels during early-mid adolescence affects the acquisition of nicotine intake and the motivation to self-administer nicotine during late adolescence; and (3) to determine if tobacco nicotine content affects the development of nicotine dependence during adolescence and early adulthood in rats. Study findings may inform regulatory activities related to reducing the nicotine content in tobacco as a measure to prevent the transition to daily smoking and nicotine addiction.

Ventilation and Pulmonary Endothelium Toxicities (VaPE-Tox) of E-cigarettes: A Randomized Crossover Pilot Study

E-cigarette vapor contains toxicants that may damage lungs and airways, eventually causing chronic lung disease. Magnetic resonance imaging (MRI) measures may be used to detect and characterize the possible acute lung toxicities of e-cigarettes. Two promising approaches — hyperpolarized helium (3He)-enhanced MRI and an innovative measure of pulmonary microvascular blood flow on gadolinium (Gd)-enhanced MRI developed by the researchers — have never been used to assess e-cigarette lung toxicities. The goal of this 11-day pilot study is to test the acute effects of e-cigarette exposure on the lungs and airways using these MRI approaches in 10 healthy, young adult (ages 21-35) e-cigarette users. After a three-day pre-study period during which participants will abstain from e-cigarette use, participants will be randomized to use a standardized refillable e-cigarette with nicotine on either days 2 and 3 or days 6 and 7 of the study period; participants will then undergo both 3He-enhanced and Gd-enhanced MRI to determine the effects of e-cigarette use on the airways and blood vessels in the lungs. Study findings may provide new information regarding the effects of e-cigarettes on the lungs.

Systematic Review of Perceived Message Effectiveness Measures for Anti-Tobacco Communication

The development and evaluation of tobacco education campaign messages are often based on participants’ perceived message effectiveness (PME). However, PME conceptualization and measurement vary greatly across research studies. The goal of this study is to conduct a systematic literature review and meta-analysis of PME measures for tobacco control. Study aims are: (1) to conduct a systematic literature review to identify the conceptual and methodological characteristics of PME measures used in studies of video and print advertisements, and (2) to identify investigators’ purpose in using PME and synthesize the outcomes and predictive findings from PME studies. To achieve Aim 1, investigators will search research databases, unpublished literature, and references in review and primary articles; code all relevant articles on participant and study characteristics as well as PME conceptualization and measurement; and summarize various aspects of PME measures. To achieve Aim 2, investigators will code investigators’ purpose in using PME; summarize study findings; identify studies that use PME as a predictor of advertisement effectiveness; and conduct a meta-analysis of the association between PME and advertisement effectiveness (e.g., tobacco quit intentions). Research findings will help optimize and enhance PME measures for future research so that optimal tobacco education messages can be developed.

Psychometric Validation of an E-Cigarette Purchase Task in Users of Advanced Generation

The use of e-cigarettes, particularly advanced-generation refillable e-cigarettes, is rapidly growing. However, little is understood about the strength of users’ motivation to continue using e-cigarettes, known as reinforcing efficacy. One tool for assessing reinforcing efficacy is a behavioral economic purchase task, in which participants estimate their daily consumption of a product at escalating prices; if demand for the product remands strong even as prices rise, then the product’s reinforcing efficacy is strong. To date, a purchase task specifically designed for e-cigarettes has not been validated. In preliminary work, the investigator developed two versions of an e-cigarette purchase task (E-CPT) in which daily consumption was measured either in puffs or in mLs of nicotine liquid. The goal of this study is examine the validity of both versions of the E-CPT to determine which one is a better measure of use behavior and reinforcing efficacy. Study aims are: (1) to validate indices of demand derived from an E-CPT against laboratory measures of e-cigarette use behavior and dependence in refillable e-cigarette users, and (2) to determine which daily unit of consumption (puffs or mLs of nicotine liquid) more accurately reflects actual use behavior. In this study, 120 refillable e-cigarette users (ages 18-60) will complete both versions of the E-CPT as well as other self-report measures of e-cigarette use and dependence. Then, participants will be videotaped using their own refillable e-cigarette for one hour. Measures of demand derived from the E-CPT will be compared with puffs taken, inter-puff interval, and other measures of use and dependence in order to determine which version of the E-CPT better characterizes the actual use of these products. Additional analyses using the validated version of the E-CPT will examine whether demand indices predict current cigarette use, traditional cigarette quit status, and other variables. This project will result in a validated measure of the reinforcing efficacy of refillable e-cigarettes that can be used to describe user behavior and provide insight into how behavior might change as a function of e-cigarette price changes.

Vape Tricks on Social Media: Implications for Electronic Cigarette Regulation for Youth

Many adolescents are exposed to nicotine and other potentially harmful constituents through the use of e-cigarettes. Identifying appealing e-cigarette components and marketing strategies can inform strategies to reduce youth e-cigarette use. In previous research, investigators determined that adolescent e-cigarette users found the ability to perform “smoke tricks” using e-cigarettes to be highly appealing. However, no information is available about how vaping images in advertisements entice youth and how social media communications teach youth how to modify e-cigarettes to produce “smoke tricks.” The goals of this project are to analyze social media sites popular among youth to obtain user and industry perspectives on e-cigarette characteristics and use patterns related to “smoke tricks,” as well as to identify marketing strategies that use vapor-related themes to increase the appeal of e-cigarettes to youth. Study aims are: (1) to analyze the content of YouTube videos on how e-cigarettes are manipulated and used to emit visible aerosol to produce “smoke tricks,” and (2) to assess the appeal of vaping images on the Facebook marketing pages of e-cigarette companies. Study findings may inform strategies such as product standards, advertising standards, and social media communication strategies that could reduce the appeal of e-cigarettes to youth.

Innovative Statistical Methods for Detecting and Accounting for Non-Compliance in Randomized Trials of Very Low Nicotine Content Cigarettes

Recent clinical trials on very low nicotine content (VLNC) cigarettes have examined whether reducing the nicotine content of cigarettes changes product use behavior (e.g., reducing cigarette consumption) by making cigarettes less reinforcing. However, these studies reported substantial non-compliance (i.e., smoking cigarettes other than those provided by the study). This is problematic because measures of product use behavior for these subjects are likely to be different than if they had only smoked the VLNC cigarettes assigned by the study. The goal of this project is to develop statistical methods for identifying and accounting for non-compliance in randomized trials of VLNC cigarettes and apply them to data collected by the Center for the Evaluation of Nicotine in Cigarettes (CENIC). Study aims are: (1) to develop statistical methods for estimating the probability that a subject was compliant based on his/her levels of nicotine exposure biomarkers, and (2) to develop a statistical framework for estimating the causal effect of VLNC use when noncompliance is not measured precisely. The development of these methods will result in estimates of the effects of VLNC cigarettes while accounting for the error associated with using biomarkers to identify non-compliance.

Animal Models for Evaluating the Relative Abuse Liability of Electronic Cigarettes

The goal of this study is to develop a methodology for testing the relative abuse liability of electronic cigarettes (e-cigarettes) in adolescents and to determine whether non-nicotine constituents contribute to e-cigarette abuse liability in this population. Current animal models of tobacco abuse that only examine nicotine may not be sufficient because compounds other than nicotine may contribute to tobacco abuse and the interaction or sum of all compounds in a tobacco product may determine its actual abuse liability. Therefore, new animal models involving exposure to a mixture of nicotine and other constituents derived directly from e-cigarettes would be useful to more accurately assess e-cigarette abuse liability. The goal of this project is to compare the abuse-related effects of nicotine alone versus e-cigarette aerosol extracts (which include non-nicotine constituents such as minor alkaloids) in adolescent rats. Study aims are: (1) to compare the reinforcing effects of nicotine alone and extracts as measured by intravenous self-administration, and (2) to compare formulations in terms of their aversive effects as measured by conditioned taste aversion. The methodology established in these studies will more comprehensively assess e-cigarette abuse liability and may inform future human research studies as well as regulatory activities related to nicotine or other constituents in e-cigarettes.

Effects of Menthol on Acrolein, Smoke-Induced Lung Inflammation

Acrolein, one of the most toxic aldehydes in cigarette smoke, is a respiratory irritant that contributes to the inflammation and lung disease caused by cigarette smoke. While menthol reduces the irritation response to acrolein, how menthol influences the effects of cigarette smoke and acrolein on lung inflammation is currently unknown. The goal of this in vitro cell-based study is to determine how menthol influences the effects of acrolein on lung inflammation. Study aims are: (1) to characterize and identify dose ranges of acrolein and cigarette smoke on inflammation markers in lung epithelial cells, and (2) to understand the effects of menthol on acrolein- and smoke-induced lung inflammation in lung epithelial cells. Findings will contribute new information regarding the dose ranges and mechanisms of acrolein and cigarette smoke actions related to inflammation and cell death.

Evaluation of Toxic Profiles of Tobacco Additives in a Systemic, Tiered Approach

The goal of this study is to investigate the effects of cigarette additives on in vitro mutagenicity and cytotoxicity using respiratory tract and heart cells. Investigators will first conduct a comprehensive systematic literature review to identify information on the selected additives (in unburnt and burnt form). Next, investigators will expose human airway epithelial and cardiac cell lines to freshly-generated whole cigarette smoke (using the ISO and Health Canada Intensive smoking regimens) for various assays at the air-liquid interface. Study objectives are: (1) to determine the cytotoxic potential of ingredients and/or their pyrolysis products using the neutral red assay, the lactate dehydrogenase leakage assay, and the methyl tetrazolium assay; and (2) to determine the genotoxic potential of ingredients and/or their pyrolysis products using the comet assay, Ames test, and micronucleus test.

Development of Standard Guideline Protocol for Rodent Sub-chronic Tobacco Smoke Inhalation Study

Historically, methodologies used in rodent inhalation studies have not adequately described toxicological differences between test cigarettes. This study addresses four key issues observed in the tobacco literature. The first issue is the normalization of tobacco smoke emitted from test cigarettes to 150 mg/m3 total particulate matter (TPM). One problem with this approach is that it normalizes the levels of toxic components present as particulates in tobacco smoke, potentially minimizing differences in toxicity that might arise from differences in particulate matter. A second problem with this approach is that it dilutes the smoke from different test cigarettes with different amounts of air, which results in the uneven dilution of the gas vapor phase. Importantly, the smoke mixture resulting from TPM normalization is very different from the smoke mixture to which smokers might be exposed. The second issue is that there are little available data that allow for a direct toxicological comparison between smoke mixtures generated under the ISO and Canadian Intense (CI) smoking regimens. Third, the vast majority of publicly-available data pertaining to cigarette toxicology has been generated using experimental “reference” cigarettes, which differ greatly in composition from the commercial cigarettes that smokers actually consume. Fourth, most available rodent toxicology studies in the tobacco literature do not address systemic toxicity, but rather focus only on respiratory tract endpoints. The goal of this study is to relate critical toxicological endpoints (e.g., no-observed-adverse-effect level [NOAEL], lowest-observed-adverse-effect level [LOAEL], dose-limiting toxicity) to serially diluted whole smoke from a commercial cigarette generated under the ISO and CI machine smoking regimens. In an initial range-finding study, researchers will expose Sprague-Dawley rats to mainstream smoke generated using a commercial cigarette brand following the CI smoke regimen. Researchers will measure various endpoints, including blood carboxyhemoglobin level, to monitor the rats’ health status. After establishing a reasonably high dose as a top dose, researchers will expose the rats to cigarette smoke for one hour per day for thirteen weeks under different serial dilutions of whole smoke generated under the ISO and CI regimens. Researchers will evaluate end-organ toxicity and conduct in vitro assays to identify different aspects of lung disease. The information obtained will provide: (1) the first publicly-available information on the dose-response curve of serially diluted whole smoke without manipulation of the gas-vapor phase in favor of the particulate phase, (2) a toxicological comparison of the smoke mixtures generated under the ISO and CI machine smoking regimens, and (3) the first publicly-available dose-response information using smoke from an actual cigarette consumed by U.S. smokers. This study is not meant to be the beginning of a series of in vivo toxicology studies using commercial cigarettes; rather, it is meant to provide an empirical basis for evaluation of the toxicology data presently available in the tobacco literature.

Measuring Consumer Comprehension of Displays of Harmful and Potentially Harmful Constituents in Tobacco Products and Tobacco Smoke

Section 904(d) of the Tobacco Control Act requires FDA to publish its list of harmful and potentially harmful constituents (HPHCs) in tobacco products (including quantity of each HPHC by brand and sub-brand) in a format that is understandable and not misleading to the public. The goal of the study is to gain insight on consumer comprehension of and preferences regarding presentation of information about HPHCs. Researchers will conduct a series of 50 individual in-depth interviews with adults and youth ages 14-17 years to gather information about different ways of presenting HPHC information for cigarettes, smokeless tobacco and roll-your-own tobacco. Participants will be asked questions regarding different ways of presenting HPHC information by brand and by quantity in each brand and subbrand. Interviews will be designed to answer the following questions about consumer knowledge, attitudes, and behavior: (1) What do adults and youth know and what do they perceive about HPHCs in tobacco products? (2) How, and in what formats, do adults and youth prefer to receive information regarding HPHCs? and (3) How do adults and youth understand and perceive the information about HPHCs provided in sample formats?

Effects of Atomizer Temperature on Electronic Cigarette Aerosol

There is little consensus in the scientific community on the overall toxicity of e-cigarette aerosols based on their chemical constituents, physical characteristics of the aerosols, and design parameters. There is also little published data on the accuracy of emerging temperature control technologies and how they work. The goal of this project, a joint project between FDA/CTP and FDA/Center for Devices and Radiological Health (CDRH) is to develop a methodology to correlate e-cigarette design parameters to chemical and physical aerosol characteristics. The primary study aim is to develop a methodology to correlate coil temperature and other design parameters with the resulting chemical and physical characteristics of e-cigarette aerosol. Study findings will contribute to knowledge about e-cigarette aerosol toxicity.

VCU TCORS: Comparison of Methods for Measurement of Electronic Cigarette Topography

The ability of electronic cigarettes (e-cigarettes) to deliver nicotine depends not only on their product characteristics but also on user behavior. Estimating the impact of user behavior on nicotine delivery involves measuring puffing behavior (i.e., puff topography), including puff number, volume, duration, inter-puff-interval, and flow rate. Puff topography measurement is accomplished with direct observation (e.g., video recordings of actual use) or computerized device methods. Previously, the researchers developed a computerized e-cigarette topography device, the eTop, and used it to demonstrate topography differences between users with and without e-cigarette experience. However, the eTop uses a mouthpiece that is compatible only with e-cigarette models that a have a cylindrical mouthpiece shape (i.e., “ciga-like” models). Researchers subsequently developed the mouthpiece-free eTop 2.0 for use with e-cigarette models of nearly any design and mouthpiece style, including tank models. The specific aim of this proof-of-concept study is to compare the sensitivity, reliability, and validity of the eTop, the eTop 2.0, and direct observation. Thirty experienced e-cigarette users and 30 cigarette users with no e-cigarette experience will participate in three experimental conditions that differ by these three measurement methods. Within each condition, participants will complete three e-cigarette puffing bouts, answer subjective questionnaires before and after each bout, and have their heart rate and blood pressure tested. Results will be used to determine whether the eTop 2.0 provides an accurate estimate of e-cigarette puff topography.

Detection of NNK-Induced DNA Adduct Formation in Human Air-Liquid-Interface Airway Tissue Models

The tobacco specific nitrosamine 4-(methylnitrosamine)-1-(3-pyridyl)-1-butanone (NNK) is one of the major carcinogens found in tobacco smoke; it causes gene mutations in vivo and in vitro and cancer in rodents. The aims of this six-month pilot study are: (1) to develop a liquid chromatography-mass spectrometry method to detect NNK-induced DNA adducts, and (2) to establish procedures to measure DNA damage using the Comet assay in in vitro human respiratory tract tissue models. An air-liquid-interface (ALI) model using well-differentiated primary human bronchial epithelial cells will be compared with single-layer human lung cancer cells and normal human bronchial epithelial cells. These data will be compared to in vivo adduct formation and DNA damage in rats and humans. This pilot study may guide future studies that compare NNK-induced toxicity outcomes in vitro with the findings from existing in vivo studies involving different NNK doses. Pilot study results may provide methodology to develop new in vitro respiratory tissue models in evaluations of the cancer-causing and gene mutation-related effects of inhaled carcinogens, which will be a new approach in the toxicological evaluation of tobacco products.

In Vitro-In Vivo Extrapolation of the Mutagenic Potential of NNK

Standard gene toxicity assays conducted to inform regulatory decision-making, such as the Ames’ bacterial gene mutation assay, provide only qualitative (i.e., positive, negative, equivocal) estimates of gene mutation. These estimates are difficult to translate into relevant human doses and responses, and potency in in vitro assays may or may not reflect potency in animal or human responses. In this study, researchers will “calibrate” responses in the Ames’ assay and the in vitro Pig-a assay to in vivo mutagenicity in the rat Pig-a assay. Researchers will develop mutation dose responses for a tobacco-specific mutagen (nicotine-derived nitrosamine ketone, or NNK) in the in vitro Ames’ and Pig-a assays and in the in vivo rat Pig-a assay. The goal is to assess whether or not animal and human mutagenic responses can be estimated from the Ames’ assay and in vitro Pig-a responses. This study may provide a new methodology for assessing human gene toxicity associated with tobacco products.

Extrapolation of In Vitro Acrolein Dose-Response Derived in Air-Liquid-Interface Airway Epithelial Models to In Vivo Lung Toxicity

New methods for conducting risk assessments that could reduce or replace animal testing would be valuable for assessing the human health effects of tobacco product use. Advancements in in vitro tissue models and physiologically-based computational modeling provide a potential means for better using in vitro mammalian cell assays to make quantitative assessments of human risk. This study will combine an in vitro human testing model with a chemical-specific strategy to use in vitro results to predict human responses. In this study, researchers will evaluate acrolein toxicity in human lung cell culture and air-liquid-interface (ALI) airway tissue models derived from both rat and human bronchial epithelial cells using toxicity endpoints relevant to human respiratory disease. Dose-response relationships derived from in vitro rat ALI toxicity data will then be compared with corresponding in vivo rat dose-response relationships to derive an in vitro-to-in vivo extrapolation factor for each toxicity endpoint. This extrapolation factor, along with human in vitro toxicity data, will then be input into mathematical models to predict in vivo human responses. The methodology developed in this study may allow scientists to evaluate claims of equivalent or modified health risks of tobacco products without animal testing.

OSU TCORS: Tailoring and Interactivity Website Features and their Impacts on Smokers’ Knowledge

Information about harmful and potentially harmful constituents (HPHCs) in tobacco products must be provided to the public in a way that efficiency conveys important details without causing cognitive “overload”. The specific aim of this project is to test the impact of different formats for web-based HPHC information delivery on smokers’ knowledge about HPHCs. To accomplish this, researchers will recruit 270 adult smokers and dual users (ages 18 and older) to view one of two experimental websites that vary in the depth of HPHC information and interactive features; researchers will then examine the influence of these attributes on smokers’ knowledge about HPHCs. Eye tracking technology will be used to capture detailed information about attention paid to website elements, and a “think aloud” protocol will be used to note subjects’ impressions of barriers to website usability. Study findings may provide a foundation for determining key web design attributes that can optimize consumer learning about HPHCs.

Emission Aerosol Constituents and Comparative Toxicology of Electronic Cigarettes with Flavorings

Data on the potentially toxic impact of exposure to flavors in e-cigarettes is needed. The goal of this study is to evaluate the aerosol constituents and cellular toxicity of flavored e-cigarettes. Researchers’ preliminary data indicate that flavored e-cigarette aerosols cause varying levels of oxidative stress and inflammatory cytokine release in human lung cells. In this study, researchers will use gas chromatography-mass spectrometry (GCMS) and in vitro cell-based assays to identify the chemicals formed in flavored e-cigarette liquids and vapors and compare their effects on oxidative stress, DNA damage, and inflammation. Specific aims are: (1) to identify and compare the chemical constituents (including some on FDA’s harmful and potentially harmful constituent [HPHC] list) present in e-liquids and aerosols in selected e-cigarettes with flavorings; and (2) to compare oxidative stress, DNA damage, and inflammatory responses to flavored e-cigarette aerosols in human and mouse lung epithelial cells. Assessment of flavored e-cigarette chemical constituents and toxicity may inform regulatory activities related to e-cigarettes.

Measure Development for Prediction of E-cigarette Initiation

Given the growth in e-cigarette use among young adults, developing an understanding of why cigarette smokers and non-smokers choose to use or not use e-cigarettes is critical. Assessing e-cigarette outcome expectancies (i.e., beliefs about the results of e-cigarette use) could be a key tool in predicting initiation. In this project, researchers will develop an e-cigarette expectancy questionnaire. Specific aims are: (1) to systematically assess young adult attitudes and experts’ opinions in order to develop an initial item pool for an “Electronic Cigarette Outcomes” measure; and (2) to refine the initial item pool via field testing. In the first phase of survey development (Aim 1), researchers will conduct focus groups with 80 young adults aged 18-24 years (including equal numbers of e-cigarette users, non-users, smokers, and non-smokers) and consult with an expert panel of researchers in order to develop a preliminary list of possible survey items. In the second phase, this preliminary list will be tested in 500 young adults aged 18-24 years (including e-cigarette users, non-users, smokers, and non-smokers). Researchers will then analyze the findings and use the results from these analyses to narrow down the items. The final survey will be a well-informed assessment of e-cigarette expectancies. This outcome expectancy measure for e-cigarettes will facilitate future research and may inform the development and evaluation of public health interventions.

CTP Supplement to Parent Grant: The Impact of Tobacco Exposure on the Lungs Innate Defense System

The heating of e-cigarette liquids can generate new and potentially toxic chemicals, and temperature is a major factor in causing e-liquid ingredient decomposition. The goal of this project is to determine the effect of temperature-dependent heating on e-liquid aerosol composition, and to evaluate the biological effects of the resulting aerosols on lung function. Specific aims are: (1) to determine the aerosol composition of e-liquids subjected to different temperatures; and (2) to determine the biologic effects of aerosols resulting from different temperatures on airway epithelial and macrophage function. To address Aim 1, researchers will generate vapors from four e-cigarette liquids (i.e., two e-cigarette liquids [menthol tobacco and vanilla tobacco] with and without nicotine) at different temperatures and will analyze the resulting aerosols using mass spectrometry techniques. To address Aim 2, researchers will measure the effects of the aerosols on cell growth, signaling, viability, oxidative stress and inflammatory responses on human airway epithelial cells. Study findings may inform regulatory activities related to e-cigarettes.

A-TRAC TCORS: Toxicity of Flavors

Many tobacco products – including cigars, cigarettes, cigarillos, and e-cigarettes – contain artificial flavors to enhance palatability and appeal. However, the toxicity of many of these flavors, especially when inhaled after heating or burning, is unknown. Specific aims of this project are: (1) to identify and quantify the chemical products generated due to the thermal degradation that occurs when tobacco product flavorings are heated or burned; and (2) to compare the relative toxicity of different flavorings commonly used in tobacco products before and after burning or heating. To address Aim 1, researchers will heat or burn major classes of common tobacco product flavor chemicals (i.e., alcohols, phenols, aldehydes, esters, ethers, hydrocarbons, ketones, lactones, organic acids, pyrazines, pyridines, pyrones) to determine the extent of degradation. To address Aim 2, researchers will use in vitro assays to measure whether chemicals from each major class of common flavor chemicals cause human platelet adhesion, human endothelial cell activation, and myocardial excitability; researchers will then compare results from these assays to discern the cardiac harm potential of different tobacco product flavorings and their thermal degradation products. This project may inform regulation related to flavored tobacco products.

Effect of Temperature-Dependent Heating On E-Liquid Aerosol Composition and of the Resulting Aerosols on Lung Function

The heating of e-cigarette liquids can generate new and potentially toxic chemicals, and temperature is a major factor in causing e-liquid ingredient decomposition. The goal of this project is to determine the effect of temperature-dependent heating on e-liquid aerosol composition, and to evaluate the biological effects of the resulting aerosols on lung function. Specific aims are: (1) to determine the aerosol composition of e-liquids subjected to different temperatures; and (2) to determine the biologic effects of aerosols resulting from different temperatures on airway epithelial and macrophage function. To address Aim 1, researchers will generate vapors from four e-cigarette liquids (i.e., two e-cigarette liquids [menthol tobacco and vanilla tobacco] with and without nicotine) at different temperatures and will analyze the resulting aerosols using mass spectrometry techniques. To address Aim 2, researchers will measure the effects of the aerosols on cell growth, signaling, viability, oxidative stress and inflammatory responses on human airway epithelial cells. Study findings may inform regulatory activities related to e-cigarettes.

Investigation of Consumer Perceptions of Implied Modified Risk Claims

Section 911 of the Tobacco Control Act prohibits tobacco labels, labeling, or advertisements that include the descriptors “light,” “mild,” “low,” or other descriptors that imply lower risk or harm. The goal of this project is to identify modified risk tobacco product (MRTP) claims that act as similar descriptors on labels, labeling, and advertising. Study aims are: (1) to determine whether hypothesized implied MRTP claims convey modified risk to consumers, (2) to determine whether implied MRTP claims affect consumer perceptions of risk, harm, and exposure to harmful chemicals, (3) to determine whether and how consumer perceptions of risk, harm, and exposure vary among different populations exposed to implied MRTP claims, and (4) to determine the similarities and differences when implied MRTP claims are viewed on labeling versus in advertisements. Approximately 6,300 adolescent, young adult, and adult tobacco users and non-users will participate in an online experimental study of three hypothesized implied MRTP claims on tobacco labeling and advertising for three tobacco products (cigarettes, smokeless tobacco, and e-cigarettes). Participants will be randomly assigned to view one of three claims or a control claim with no MRTP information. Participants will also be randomly assigned to the types of products and media they will view. Participants will be asked to provide their assessments of risk, harm, and exposure to harmful chemicals for the product label or advertisement viewed. This project will provide insights about how consumer perceptions of the risks and harms of tobacco products are influenced by implied MRTP claims on packaging and labeling.

Does Abstinence from E-cigarettes Produce Withdrawal Symptoms?

Many e-cigarette users achieve nicotine blood levels from e-cigarettes that are much higher than those from nicotine replacement products and, in some studies, similar to those of cigarette users. Accordingly, abrupt cessation of e-cigarettes could be expected to produce withdrawal symptoms, an important feature of addiction; however, this hypothesis has not been tested. The specific aim of this study is to determine whether abruptly stopping e-cigarette use causes withdrawal symptoms. Researchers will recruit 80 adult (ages 18 and older) long-term e-cigarette-only users and instruct them to use their own e-cigarettes for five days and then abruptly stop using them for five days.  Participants will monitor symptoms of nicotine withdrawal daily by calling an interactive voice response system each night.  Abstinence from e-cigarettes will be supported by payments contingent on breath and saliva samples. Participants will attend three laboratory visits each week to provide carbon monoxide and cotinine samples to verify abstinence, complete longer surveys, and complete a task to measure whether their motivation to use e-cigarettes has increased. Study results will help determine the addiction potential of e-cigarettes.

Focus Groups on ENDS: Device Types, User Experiences, and Product Appeal

Electronic nicotine delivery systems (ENDS), including e-cigarettes, are growing in popularity. The goal of this study is to understand how ENDS device characteristics influence users’ experiences, and how these experiences shape ENDS use behavior, beliefs, and attitudes. Researchers will conduct 23 focus groups with a total of 156 participants who are users of “cigalikes” (non-customizable devices that look similar to cigarettes) or “tank systems” (advanced-generation, customizable devices). Focus groups will be conducted in four locations — New York, NY; Chicago, IL; Memphis, TN; and Denver, CO – and will be segmented by type of device used. Groups will be conducted with young adults (ages 18-29 years) and adults (ages 30+ years); and will include a mix of ages, sex, races/ethnicities, education levels, and rural/urban geography.

UNC TCORS: Optimizing Public Display of Information on Tobacco Product Constituents

As directed by the Tobacco Control Act, the FDA Center for Tobacco Products is required to disclose information about harmful and potentially harmful constituents (HPHCs) in tobacco products to the public in a format that is “understandable” and “not misleading to a lay person.” The specific aim of this study is to identify website formats and content that increase comprehension of HPHC information, especially among people with lower health literacy. To investigate this aim, researchers will meet with legal scholars to better conceptualize the Tobacco Control Act’s language regarding comprehension of HPHC information (i.e., “understandable,” “not misleading”). They will also design and pilot test website variations for presenting information about HPHCs in ways that are “understandable” and “not misleading” to the public. After this developmental work, researchers will conduct an online study involving 1,400 adolescents (ages 13-17), young adults (ages 18-25), and adults (ages 26 and older). The study will identify website characteristics that lead to higher comprehension and may inform regulatory activities related to the communication of HPHCs.

Yale TCORS: Irritant Flavor Products in Heated E-Cigarette Liquids and Vapors

While many of the flavorings used in e-cigarette liquids are generally recognized as safe in food, the safety of inhaling flavorings when using e-cigarettes has not been established. Popular e-liquid flavor mixes contain aldehydes such as cinnamaldehyde (cinnamon), carvone (spearmint), and terpenoids such as menthol (mint) and limonene (citrus). Notably, aldehydes and other chemicals are known to activate the transient receptor potential (TRP) ion channels in respiratory cells, thereby causing irritation in the respiratory system. The goal of the project is to study the impact of flavor chemicals on the TRP ion channels. Specific aims are: (1) to identify the chemical reaction products of e-liquid flavorings produced during heating and aerosolization; (2) to compare responses of TRP ion channels to e-liquids and their aerosols; and (3) to examine the sensitivity of newly-identified chemosensory receptors to flavorings and their products. To investigate these aims, researchers will use a variety of analytical techniques, including high performance liquid chromatography-mass spectrometry (HPLC-MS), gas chromatography-mass spectrometry (GC-MS), gas chromatography-flame ionization detector (GC-FID), and other screening approaches. The study will provide new data that may inform regulatory activities related to toxic and potentially toxic constituents in e-cigarette liquids.

Assessing the Intended and Unintended Consequences of E-cigarette TV Advertising

To date, no studies have examined the population level impact of televised e-cigarette advertising. The goal of this project is to examine the effects of televised e-cigarette advertising. Specific aims are: (1) to examine the impact of e-cigarette television advertising on awareness, risk perceptions, intentions to use, initiation, and patterns of use of e-cigarettes and conventional cigarettes; (2) to assess the potential consequences of e-cigarette television advertising, examining impact on attitudes, beliefs, and behaviors related to electronic nicotine delivery systems (ENDS) and e-liquid as well as the use of e-cigarettes as substitutes for smoking cessation methods; and (3) to study whether and to what extent state and local tobacco control policies and policies restricting e-cigarette use modify the effects of e-cigarette television advertising. Researchers will conduct two nationally representative longitudinal surveys of youth and young adults (ages 15-24) and adults (ages 25-60) to measure individual attitudes, beliefs and behaviors. They will also use data from their other studies—including e-cigarette and nicotine replacement therapy sales data from commercial store scanner databases, Nielsen television ratings data for e-cigarettes and pharmaceutical cessation products, and state and local policy data related to tobacco, and e-cigarettes—to measure key contextual and policy influences on individuals’ attitudes, beliefs and behaviors. Project findings may inform future regulatory activities related to e-cigarette advertising and promotion.

Assessment of Tobacco Products and Tobacco Product Constituents’ Genetic Toxicology in In Vitro Assays: Comparative In Vitro Toxicity of Conventional Cigarettes Versus Electronic Cigarettes – Mutagenicity, Cytotoxicity, and Genotoxicity

More information about the toxicity differences between cigarette smoke and e-cigarette aerosol would be useful. The goals of this study are to compare the in vitro mutagenicity, cytotoxicity, and genotoxicity of total particulate matter (TPM) generated from conventional cigarettes to that of e-cigarettes, and to characterize the qualitative and quantitative profiles of conventional cigarette smoke and e-cigarette aerosols. Researchers will select 15 cigarettes of different brands and six e-cigarettes representative of first, second and third generation devices based on market share. Researchers will generate TPM from conventional cigarettes using the Canadian Intense (CI) and the International Organization for Standardization (ISO) regimens, and generate TPM from e-cigarettes using a modified puffing protocol described by Behar et al. (PLoS One 2015;10(2):e0117222). They will then quantify nicotine in TPM from each of the samples collected and measure nicotine and cotinine levels using the gas chromatography-mass spectrometry (GC-MS) method. Cytotoxicity will be assessed using the Neutral Red Uptake assay; genotoxicity will be assessed using the micronucleus assay; and mutagenic potency will be assessed using the bacterial Ames test and the thymidine kinase gene mutation assay. Study findings will provide new information about the differences in toxicity profiles between cigarette smoke and e-cigarette aerosol.

Flavoring Compounds in Tobacco Products

Although the popularity and use of flavored e-cigarettes and other flavored tobacco products continues to increase, particularly among youth, data on the potential human health effects of these products are limited. In the early 2000s, concerns were raised about chemicals used in flavorings after workers at a microwave popcorn factory were diagnosed with the respiratory disease bronchiolitis obliterans; the disease was attributed to their inhalation of diacetyl, a butter flavoring compound. Diacetyl and its replacements (2, 3-pentanedione and acetoin) are used in the manufacture of many foods to create a wide range of flavors (e.g., caramel, cream, pina colada, strawberry). Many of these flavors are common in e-cigarette flavor cartridges, and users of e-cigarettes are directly inhaling these flavoring compounds. The goals of this study are: to quantify the concentrations of these flavoring compounds in e-cigarette liquids and aerosols; to estimate exposures for users of e-cigarettes; to profile airway epithelial cells; and to conduct in vitro assays for inflammation, cell proliferation and apoptosis. . Researchers will conduct a market survey to identify the top brands of flavored e-cigarettes and other categories of flavored tobacco products (i.e., flavored cigarettes and cigars, including little cigars and cigarillos) available for purchase in U.S. retail outlets, and then test samples of 51 products. Results may inform regulatory activities related to flavoring compounds used in e-cigarettes and other combusted tobacco products.

Nicotine Self-Administration with Flavor Cues

Flavor additives in tobacco products and e-cigarettes may increase their appeal and encourage experimentation, repeated use, and dependence, even when only small amounts of nicotine are available. Many of the flavors in tobacco products are “incentives” – stimuli that have become rewards because of their inclusion in foods and beverages. For example, strawberry and licorice flavors become incentives because they are consumed in sweet foods that are high in calories before people use tobacco or vapor products. The goal of this study is to evaluate whether the psychological value of flavor additives interacts with nicotine to increase motivation to self-administer the drug in a rat model. Specific aims are: (1) to investigate which specific flavors (menthol, licorice, strawberry, or cocoa) promote the most nicotine self-administration; (2) to investigate whether these flavor incentives increase dependence-like behavior when they are self-administered with nicotine; and (3) to investigate whether the combination of incentive flavors and nicotine will increase the release of dopamine, a brain chemical that contributes to compulsive substance use and dependence. Researchers will give one flavor (e.g., menthol) psychological appeal by pairing it with sugar (e.g., incentive flavor); a second “unsweetened” flavor will serve as a control (e.g., neutral flavor). During testing, rats will be tethered to a leash that can deliver nicotine intravenously. One of four nicotine doses (0, 3, 10, or 60 ug/kg/infusion) will be delivered when rats lick a sipper tube with the flavors. Each time the rat receives a nicotine infusion, a few drips of a flavor (incentive or neutral) will be released into the sipper tube. This procedure mimics the fast delivery of nicotine to the brain in conjunction with the oral perception of flavor additives during vaping and smoking. To more closely model smoking and vaping, the flavors will be presented “unsweetened” during these tests. Based on past research and preliminary data, the investigators have hypothesized that an interaction between nicotine and the incentive flavors will promote drug-taking at low doses, increase the motivation for nicotine, increase levels of dopamine in the brain, and increase dependence-like behavior. Findings may inform regulatory activities related to flavors.

Golestan Tobacco Biomarkers Study

Epidemiologic studies that link tobacco exposure biomarkers (measurable indicators of exposure) to adverse health effects are valuable for complementing existing toxicological information about harmful and potentially harmful constituents (HPHCs) present in tobacco products. The goal of this study is to examine associations between tobacco exposure biomarkers and tobacco-related diseases using the Golestan Cohort Study, a study that includes more than 50,000 adults (ages 40-75 years) in Northern Iran; subjects have provided urine specimens and tobacco use data and have been followed since 2004 for disease and mortality outcomes. Study aims are: (1) to characterize mean levels and distribution of tobacco constituents in users’ urine by type of tobacco used (e.g., cigarettes, hookah); (2) to compare the stability of biomarker levels over time in current smokers; and (3) to estimate associations between individual biomarkers of polyaromatic hydrocarbons (PAHs), volatile organic compounds (VOCs), and tobacco-specific nitrosamines (TSNAs) and the risk of disease and death. To accomplish these aims, investigators will first conduct a pilot study to assess biomarker levels in tobacco users and non-users and compare biomarker levels at two different time points. Second, investigators will conduct a full study in which they will define groups based on disease (i.e., cancer, heart disease, stroke, respiratory disease) as well as a control group. They will then examine the association between pre-diagnostic levels of urinary biomarkers of nicotine, PAHs, VOCs, and TSNAs and the risk of each disease. The results of this study will provide information on the associations between biomarkers of exposure and adverse health effects and may help to inform regulatory actions regarding HPHCs.

Investigation of Consumer Perceptions of Expressed Modified Risk Claims

Modified risk tobacco products (MRTPs) are products whose packaging or advertising states the products are less risky than other tobacco products. The goal of this project is to understand more about how MRTPs are perceived. Study aims are: (1) to develop and validate measures of risk beliefs and knowledge about tobacco products; (2) to identify groups who may be more likely than others to misunderstand product risk information or who may be particularly affected by the marketing of MRTPs; and (3) to test debriefing procedures to reduce the lingering effects of viewing (hypothetical) risk information. Two experiments will be conducted on a total of 6,000 adult tobacco users and non-users participating in an Internet survey panel. One experiment will focus on smokeless tobacco and the other on e-cigarettes. Participants will view an image of a package or advertisement for a smokeless tobacco or e-cigarette product. The product will be presented with or without hypothetical statements about the risks of using the product compared to smoking cigarettes. Participants will then be asked about their perceptions of the risks associated with using the product, and their intention to use the product. The debriefing will explain that the statements about the product’s risks may not be true and were created for the purposes of the experiment. The debriefing will differ in terms of format (a standard block of text format vs. a more visually pleasing ‘bubble’ format) and content (standard vs. expanded content). The information collected by this study may inform regulatory activities related to the marketing of MRTPs.

Investigation of Consumer Perceptions of Expressed Modified Risk Claims

Modified risk tobacco products (MRTPs) are products whose packaging or advertising states the products are less risky than other tobacco products. The goal of this project is to understand more about how MRTPs are perceived. Study aims are: (1) to develop and validate measures of risk beliefs and knowledge about tobacco products; (2) to identify groups who may be more likely than others to misunderstand product risk information or who may be particularly affected by the marketing of MRTPs; and (3) to test debriefing procedures to reduce the lingering effects of viewing (hypothetical) risk information. Two experiments will be conducted on a total of 6,000 adult tobacco users and non-users participating in an Internet survey panel. One experiment will focus on smokeless tobacco and the other on e-cigarettes. Participants will view an image of a package or advertisement for a smokeless tobacco or e-cigarette product. The product will be presented with or without hypothetical statements about the risks of using the product compared to smoking cigarettes. Participants will then be asked about their perceptions of the risks associated with using the product, and their intention to use the product. The debriefing will explain that the statements about the product’s risks may not be true and were created for the purposes of the experiment. The debriefing will differ in terms of format (a standard block of text format vs. a more visually pleasing ‘bubble’ format) and content (standard vs. expanded content). The information collected by this study may inform regulatory activities related to the marketing of MRTPs.

Heating Flavor Chemicals in E-cigarette Liquids – Supplement to Metals in Electronic Cigarettes Aerosol

The effects of heating flavor chemicals in e-cigarette liquids on human health are largely unknown. The goals of this project are to identify and quantify the reaction products formed during heating of flavored e-cigarette liquids and to determine which tests can best identify the flavor chemicals and reaction products that are harmful to the human respiratory system. Specific aims are: (1) to identify and quantify the primary flavor chemicals and major flavor-derived pyrolysis/oxidation products formed during use of approximately 100 e-cigarette refill fluids and disposable e-cigarettes; (2) to screen individual chemicals identified in Aim 1 in unheated e-cigarette fluids and aerosol condensates for toxic effects in human respiratory system cells; and (3) to test the most toxic chemicals identified in Aim 2 using air-liquid interface (ALI) technology.  Researchers will conduct the experiments using a variety of methods, including gas chromatography/mass spectrometry (GC/MS), two-dimensional GC with MS, liquid chromatography/MS/MS, a moderate throughput (MTT) assay, and an ALI system that resembles a human lung. Study findings may inform regulatory activities related to flavorings in e-cigarettes.

CTP Supplement to Parent Grant: Nicotine Delivery from Novel Non-Tobacco Electronic Systems

Data on the inhalation toxicity of flavorings used in electronic nicotine delivery systems (ENDS) are limited. The goal of this study is to evaluate the potential toxicity of several of the most popular flavorings in ENDS and ENDS liquids sold in the U.S. This study will assess the concentration, emission, and potential degradation of flavorings from storage or heating as well as the cellular toxicity of different flavorings in ENDS aerosols. Specific aims are: (1) to determine flavoring type and amounts in 32 disposable ENDS products, cartridges and refill solutions, as well as inter-brand and intra-brand variability in flavorings; (2) to determine the stability of flavorings under various storage conditions; (3) to determine flavoring yields in vapors from various types of ENDS; (4) to determine the effect of various product characteristics on flavoring levels in aerosols; (5) to compare the cellular effects of flavored ENDS aerosols versus tobacco smoke; and (6) to establish an evidence base for evaluating potential harm to users. One study, which will address Aims 1 and 2, will involve laboratory analytical chemistry testing of multiple brands and batches of flavored ENDS in order to characterize flavored ENDS products. A second study, which will address Aims 3 and 4, will involve laboratory analytical chemistry testing to determine flavoring yields in aerosols from various types of ENDS. A third study, which will address Aims 5 and 6, will test the cellular toxicity of aerosol generated from flavored ENDS using an air-liquid interface (ALI) model to measure the effects of aerosol on non-cancerous bronchial epithelial cells and mutated lung cancer cell lines. Study findings may inform the development and implementation of standard quality assessment procedures and testing methods for flavored ENDS.

Evaluation of the NYC Cigar Packaging and Pricing Law

In 2014, New York City (NYC) implemented a cigar pricing and packaging law that mandates that cigars sold for $3 or less must be sold in a package of at least four cigars and that little cigars must be sold in packs of at least 20 and for at least $10.50 per pack. The NYC cigar law is part of a law with multiple tobacco control measures that aim to reduce tobacco use by decreasing the availability of low-priced tobacco products in NYC. The NYC cigar law provides an opportunity to evaluate the implementation and outcomes associated with this type of change in the retail environment. This evaluation will focus on whether the cigar pricing and packaging law was implemented as planned, whether it achieved its intended impacts on tobacco product sales and use, and whether it had any unintended consequences.  As part of the evaluation, investigators will collect and analyze retailer scanner data to study product pricing, sales volume and product characteristics pre- and post-policy implementation within New York City and comparison areas; conduct population health surveys to collect quantitative data on tobacco use and identify cigar-related outcomes; collect social media data to monitor the content and reach of social media activity related to cigar pricing and packaging; and gather tobacco retailer observations in New York City and surrounding areas to assess packaging and pricing in the retail environment. Study findings will provide new information on a number of topics, including trajectories of cigar consumption by product type; comparisons of cigars with other combustible and non‐combustible tobacco products with regard to consumer use, sales, and availability; and expected outcomes of a cigar product pricing and packaging policy within a specified jurisdiction.

Context and Subjective Experience Surrounding Dual Cigarette and E-Cigarette Use

More information is needed about e-cigarette use and its association with other factors, such as continued use of conventional cigarettes, nicotine dependence, and changes in tobacco use patterns.  This project will use Ecological Momentary Assessment (EMA), a research methodology that gathers information about real-world experiences in real time, to collect reports of dual product (cigarette and e-cigarette) users’ daily tobacco use. Researchers will examine how the immediate context of tobacco use and individuals’ subjective reactions vary by product and individual characteristics and influence future use patterns. Researchers will recruit 450 adult cigarette smokers (ages 18 and older) who also use or report that they are likely to use e-cigarettes and conduct two one-week waves of EMA using smartphone interview “apps” and biweekly email surveys for one year. Specific aims are: (1) to examine the contexts of tobacco use (e.g., mood, alcohol use) and how they vary by product and individual differences (e.g., demographics, tobacco history, dependence) in order to understand the functional value of e-cigarettes; (2) to examine real-time withdrawal, cravings, and satisfaction with tobacco products and how these affect transitions in tobacco use; and (3) to examine how tobacco cues relate to tobacco use experiences, contexts, and patterns of use. This information may inform regulatory activities related to e-cigarettes.

CTP Supplement to Parent Grant: Nornicotine in Smokeless Tobacco as a Precursor for Carcinogen Exposure

The Tobacco Control Act requires that the amounts of harmful and potentially harmful constituents (HPHCs) reported by tobacco manufacturers to the FDA be disclosed to the public in a format that is understandable and not misleading. Previous research, which was largely focused on cigarette smoke constituents, showed that consumers generally have inadequate awareness and understanding of the chemicals in tobacco products, and may be misled into believing that lower amounts of specific constituents in cigarette smoke directly translate into reduced health risks. However, research on consumer perceptions of constituent levels in smokeless tobacco products is extremely limited. The goal of this project is to investigate the comprehension of different presentations of smokeless tobacco product HPHC lists by conducting an online survey of 1,500 individuals ages 18 and older. Specific aims are: (1) to investigate differences in consumer understanding of information about smokeless tobacco product HPHCs displayed in two formats (graphic and numerical), as well as differences in health risk perceptions and search behaviors as a function of the display format; and (2) to investigate which consumer characteristics moderate knowledge levels, inferences, and search behavior in the context of the two different display formats. Study findings will provide important information on effective communication of smokeless tobacco constituent levels to lay persons in general and to smokeless tobacco users specifically.

Nicotine Pharmaockinetics and Salivary pH of Large and Small Cigar Smokers

Cigar products are diverse, varying in tobacco weight, nicotine concentration, and tobacco pH. Despite rapid increases in cigar smoking prevalence, the risks of nicotine exposure and addiction have not been systematically studied. For example, although tobacco pH is an important factor in nicotine absorption, there is little evidence of how cigar tobacco pH affects nicotine bioavailability and nicotine absorption, two fundamental aspects in understanding a product’s addictive potential. The goal of this study is to evaluate the nicotine pharmacokinetics and salivary pH of cigar smokers. Specific aims are: (1) to chemically characterize 20 cigars for nicotine content and tobacco pH; and (2) to evaluate the relationship among tobacco pH, salivary pH, and nicotine exposure in non-inhaling large (n=24) and small (n=24) cigar smokers. In three separate sessions designed to equate nicotine consumption, participants will smoke their own brand cigar and two cigars with similar nicotine content but different tobacco pH. Nicotine exposure, subjective effects, and salivary pH will be measured and compared. Study findings will provide new information about the impact of cigar tobacco pH and its relationship with oral nicotine absorption resulting from cigar use. 

Effect of pH of Smokeless Tobacco Products on the Pharmacokinetics of Nicotine in Current Users

The absorption of nicotine from smokeless tobacco (ST) may be affected by the pH of the product. Increasing the pH of an ST product increases the amount of free base nicotine (the most potent and easily-absorbed form of nicotine) and may increase absorption through the mouth. Although ST products are typically buffered with an alkaline pH (presumably) to facilitate oral absorption of nicotine, clinical data examining this phenomenon are sparse. The goal of this study is to determine whether increasing the pH of an ST product correlates with free base nicotine exposures measured clinically. Study aims are: (1) to evaluate the effect of pH values on the nicotine pharmacokinetics of ST products; and (2) to evaluate the pharmacodynamic effects (e.g., subjective and physiological effects) of ST products with prospectively adjusted pH values. Investigators will ask 40 adult ST users to test one of four ST products (with an adjusted pH of 5, 7.7, 8.2, and 8.6) or a placebo product. Participants will use each product for 30 minutes during a laboratory session. During each session, a series of blood samples will be obtained to determine the time course and nicotine levels resulting from ST product use. In addition, subjective assessments will be administered to determine the qualitative effects of ST product use (e.g., questions about “liking”). Study findings may inform regulatory activities related to smokeless tobacco.

Effects of Nicotine Reduction on Smoking Behavior in ADHD Smokers

Compared to the general population, individuals with attention deficit hyperactivity disorder (ADHD) are more likely to smoke, start smoking at a younger age, smoke more, become more dependent, and have a harder time quitting. Reducing the nicotine content of cigarettes has shown promising beneficial effects in the general population, but individuals with ADHD may respond with compensatory increases in smoking, potentially increasing exposure and adverse health effects. The goal of this project is to examine the effects of very low nicotine content (VLNC) cigarettes on smoking behavior and clinical functioning in 200 young adult smokers (ages 18-40) with ADHD. Researchers will randomly assign participants to smoke experimental cigarettes with very low (0.05 mg/cigarette) or conventional (0.8 mg/cigarette) nicotine yield for six weeks, during which participants will provide daily feedback using a telephone-based interactive voice response system and attend weekly visits during which researchers will measure a range of smoking and ADHD-related outcomes. Specific aims are: (1) to assess how VLNC cigarettes impact cigarette smoking and related biomarkers (i.e., expired air carbon monoxide, urine cotinine) and nicotine dependence; (2) to assess how reduced nicotine content influences ADHD symptoms and related measures of cognition (i.e., inhibitory control, working memory) and overall clinical functioning; and (3) to evaluate outcomes associated with acceptability (i.e., withdrawal, study dropout, compliance) and safety/adverse outcomes (i.e., changes in physical health, alcohol/drug use, use of other tobacco products). Data from this study may inform regulatory activities regarding reduced-nicotine tobacco products.

New, Emerging, and Traditional Tobacco Use in the Military

U.S. military personnel are highly vulnerable to tobacco use; currently, more than 30% of active duty military personnel use some type of tobacco product. Researchers will investigate military personnel perceptions, use of traditional, new and emerging tobacco products, and risk factors for use. Specifically, researchers will collect data on 30,000 Airmen, Air National Guard members, and reservists by administering a 97-item written survey at three timepoints (baseline, one year, two years) at the five largest U.S. Technical Training Air Forces Bases. Specific aims are: (1) to determine the prevalence and incidence of traditional, new and emerging, and multiple tobacco product use; (2) to determine social-cognitive (e.g., self-efficacy) and affective (e.g., perceptions, attitudes, beliefs) factors associated with the use of new and emerging tobacco products (such as e-cigarettes, hookah, cigars, and snus) and traditional tobacco products (e.g., smokeless tobacco, little cigars); (3) to evaluate perceptions and beliefs about risks and harms of tobacco product use; (4) to assess the association among awareness of tobacco marketing strategies (e.g., free samples of non-regulated products such as e-cigarettes, price promotions), receipt of information about tobacco products, and tobacco use behaviors; and (5) to directly compare tobacco initiation, resumption, and predictors of tobacco use between Airmen (who remain in active duty) and National Guard/reservists (who train and then return to civilian life). Findings will clarify the prevalence, incidence and diversity of tobacco product use in this highly-vulnerable population and may inform future regulatory activities.

Toxicant Production and Mitigation in the Electronic-Cigarette Reaction Vessel

E-cigarettes are growing in popularity; however, their health effects are unknown. The goal of this project is to clarify the origins and levels of toxins produced during e-cigarette use as well as the properties of the particles inhaled by users and those exposed to secondhand aerosol. Specific aims are: (1) to define the effect of use on glycerol and propylene glycol, the primary aerosol-forming molecules; (2) to define the effect of use on nicotine and related alkaloids likely to be present in some e-cigarette liquids; (3) to define the effect of flavorings and environmental contaminants on electronic nicotine delivery systems; and (4) to determine the ability of formaldehyde to be released from carrier product molecules and to examine the toxicities of e-cigarette aerosols using various bioassays. Using laboratory analysis techniques such as gas chromatography-mass spectrometry (GC-MS) and nuclear magnetic resonance, researchers will generate predictive models that estimate the products of use and particle size distributions. Study findings may inform regulatory activities related to e-cigarettes.

Literature Review of the Impact of Tobacco Quantity on Consumer Perceptions, Intentions, and Use Behavior

Research is limited on how different elements of tobacco packaging (e.g., package dimensions, package volume, portion size, portion count per package) affect consumer perceptions, use intentions, and use patterns. The goal of this project is to provide a systematic review of the scientific literature to identify and summarize how the amount of tobacco product in a package affects customer perceptions (e.g., risk/harm perceptions, curiosity, attitudes, beliefs), use intentions (e.g., purchase intentions, use intentions, quit intentions), and use patterns (e.g., product uptake, product re-uptake, increased/decreased product use) of consumer products, with a specific focus on tobacco products. A secondary objective is to identify public health, marketing/sales, and other sources of data related to the effect of these variables on consumer perceptions, use intentions, and use patterns. Study findings may inform regulatory activities related to tobacco packaging.

Cardiovascular Toxicity of Tobacco Products and Constituents

Tobacco product use is associated with increased risk of cardiovascular disease. The goals of this project are to quantify and evaluate the cardiovascular toxicity of the major aldehydes in tobacco products and to validate the association between exposure to these aldehydes and cardiovascular toxicity in humans. Specific aims are: (1) to assess the contribution of aldehydes to the cardiovascular toxicity of tobacco products in mice; (2) to evaluate the cardiovascular toxicity of individual aldehydes and the toxicity modification by nicotine in mice; and (3) to identify aldehyde-induced cardiovascular toxicity in humans. To address Aim 1, researchers will conduct acute and chronic inhalation studies to expose adult male mice to cigarette smoke containing variable levels of acetaldehyde, acrolein, and formaldehyde (which are classified by the FDA as harmful and potentially harmful constituents [HPHCs]) within the range of commercially-available cigarettes or e-cigarette aerosols and evaluate cardiovascular risk factors, including changes in thrombosis, insulin resistance, and plasma lipids. To address Aim 2, researchers will expose adult male mice to different levels of individual aldehydes to determine the dose-response relationship between aldehyde exposure and cardiovascular injury; they will also examine how the presence of nicotine affects aldehyde toxicity and metabolism, and whether dual exposure to tobacco smoke and e-cigarette aerosol results in increased cardiovascular toxicity. To address Aim 3, researchers will use banked blood and urine samples from 350 high-risk cardiovascular disease patients (adult smokers and nonsmokers over age 21 already enrolled in the Louisville Healthy Heart Study) to evaluate whether the cardiovascular toxicity profiles in human smokers are comparable to patterns of aldehyde-induced toxicity in mice. Study findings will provide information about how major aldehydes present in cigarette smoke and e-cigarette aerosols contribute to cardiovascular toxicity.

Stability Study for Reference Cigarette Tobacco Filler

Little publicly-available information exists regarding the short- and long-term stability of cigarette tobacco filler. Depending on storage conditions and packaging, the characteristics of the tobacco filler may change over time. This project will determine the stability of cigarette tobacco filler at three-month intervals over a 12-month period of time for the certified reference material (SRM 3222) developed at the National Institute of Standards and Technology (NIST). Stability testing will include monitoring the effects of storage temperature and time on levels of three harmful and potentially harmful constituents (HPHCs) — nicotine, N-nitrosonornicotine (NNN), and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) — as well as on moisture and pH in cigarette tobacco filler. Stability testing will be conducted using validated, analytical methods.

PATH Study Analysis Assays of Multiple Analytes

The Population Assessment of Tobacco and Health (PATH) Study is a longitudinal, nationally representative study of tobacco use and health in the U.S. population.  A cohort of approximately 46,000 adults and youth ages 12 years and older are followed annually for three years to assess use of conventional and emerging tobacco products, attitudes and perceptions related to the use of different tobacco products, and near- and longer-term health outcomes associated with tobacco product use.  The study includes the collection of biospecimens (urine, whole blood, and buccal cells) from adults (ages 18 and older) to examine biomarkers of tobacco exposure and tobacco-related disease processes.  The goal of this project is to measure biomarkers of tobacco exposure and harm in PATH Study participant samples. Levels of interleukin 6 (Il-6) and soluble intercellular adhesion molecule-associated inflammation (sICAM) will be measured in plasma using standard enzyme-linked immunosorbent (ELISA) assays. Fibrinogen activity will be measured in serum using the Clauss assay. These data will be sent to the PATH Study data repository and merged with the main study instrument for future analyses. Results from this project may inform FDA on behaviors and exposures related to tobacco use.

Manipulating Cigarette Constituents in Male Menthol Smokers

FDA has the regulatory authority to reduce nicotine levels and ban menthol in cigarettes, but has not yet taken action in either area. In a parent study, researchers are examining the impact of these two potential regulatory actions alone and in combination on smoking behavior in 320 female menthol smokers. In this study supplement, researchers will study 57 male menthol smokers (aged 18-45) in order to examine whether there are gender differences in smoking behavior in response to reduced nicotine levels and menthol content. Specific aims are: (1) to examine gender differences in smoking rates in response to nicotine and menthol content manipulations in menthol smokers; (2) to examine gender differences in smoking motivation in response to nicotine and menthol content manipulations in menthol smokers; and (3) to explore the effect of “supertaster” status (i.e., individuals who experience taste with greater intensity than average) on tolerability of experimental cigarettes, smoking satisfaction, and smoking behavior. Researchers will randomize the male smokers to one of three alternatives – reduced nicotine content (0.07 mg) non-menthol cigarettes, reduced nicotine content (0.07 mg) menthol cigarettes, or conventional nicotine cigarettes (0.8 mg) – for six weeks with an additional six-week follow-up period. Researchers will then compare male and female data related to cigarette usage, exhaled carbon monoxide, and other measures in order to determine differences in use of, dependence on, and craving associated with experimental cigarettes. This study will provide insight into gender-based differences in the impact of menthol and reduced nicotine content cigarettes in menthol smokers.

Clinical Pharmacology of Electronic Cigarettes

Electronic cigarettes (e-cigarettes) are growing in popularity. However, their potential addictiveness and safety of use are unknown. The goal of this study is to evaluate e-cigarettes by assessing key factors associated with nicotine addiction and possible health effects. Specific aims are: (1) to characterize nicotine delivery, systemic exposure and effects following e-cigarette use; (2) to assess the possible health effects of e-cigarette use; and (3) to validate biomarkers to distinguish e-cigarette use from traditional cigarette use.  In this two-week study, 36 dual e-cigarette/traditional cigarette users (ages 18 and older) will switch between the two product types, each to be used exclusively for one week. During each week, subjects’ use and subjective assessments will be tracked for four days as outpatients followed by three days on a research ward. To address Aim 1, researchers will gather information related to the fraction of nicotine inhaled from e-cigarettes that is retained in the body and how retention is influenced by device type, e-liquid nicotine, propylene glycol and glycerin concentrations, e-liquid pH, e-liquid flavor, and battery voltage. Researchers will also evaluate users’ systemic exposure to nicotine and the amount of nicotine exhaled, and how these relate to e-cigarette product characteristics. Finally, researchers will compare e-cigarette and traditional cigarette use with regard to time to peak nicotine concentration; daily intake of nicotine; satisfaction, reward, craving and withdrawal symptoms; and puff patterns.  To address Aim 2, researchers will compare dual use, e-cigarette use alone, traditional cigarette use alone, and no product use with regard to levels of exposure to tobacco smoke toxicants (particularly volatile organic compounds) and cardiovascular effects. To address Aim 3, researchers will evaluate whether the ratio of nicotelline to nicotine metabolites (cotinine or total nicotine equivalents) in urine distinguishes e-cigarette use from traditional cigarette use.  Findings may inform regulatory activities related to e-cigarettes. 

Composition and Biologic Effects of Flavored E-Liquids

E-cigarettes are sold in many flavors, yet little is known about the impact of inhaling their chemical constituents or biological and psychophysiological effects and psychosocial influences contributing to their addictive properties. Both the tongue and the lung express taste receptors that elicit biological responses when savory, sweet and bitter compounds are detected. The goal of this supplement to an ongoing study is to determine the reinforcing properties of different e-liquid flavorings, determine the biological effects of flavored/sweet e-cigarette on taste receptors, and further determine the chemical constituents of e-liquids. Study aims are: (1) to determine the composition of flavored e-liquids by using mass spectrometry; (2) to determine the biologic effects of e-liquids by measuring the in vitro response of bitter and sweet taste receptors following exposure to common brands of e-liquids; and (3) to perform a psychophysical and psychosocial evaluation of the reinforcing properties of e-cigarette flavors, including menthol, to determine which flavors are associated with varying reinforcing and analgesic properties and how psychosocial stress affects the reinforcing properties of e-cigarettes. As part of Study Aim 3, researchers will test 75 adults (ages 18-45). Study findings may inform regulatory activities related to e-cigarette flavorings.

CTP Supplement to Parent Grant: The Impact of Tobacco Exposure on the Lung’s Innate Defense System

E-cigarettes are sold in many flavors, yet little is known about the impact of inhaling their chemical constituents or biological and psychophysiological effects and psychosocial influences contributing to their addictive properties. Both the tongue and the lung express taste receptors that elicit biological responses when savory, sweet and bitter compounds are detected. The goal of this supplement to an ongoing study is to determine the reinforcing properties of different e-liquid flavorings, determine the biological effects of flavored/sweet e-cigarette on taste receptors, and further determine the chemical constituents of e-liquids. Study aims are: (1) to determine the composition of flavored e-liquids by using mass spectrometry; (2) to determine the biologic effects of e-liquids by measuring the in vitro response of bitter and sweet taste receptors following exposure to common brands of e-liquids; and (3) to perform a psychophysical and psychosocial evaluation of the reinforcing properties of e-cigarette flavors, including menthol, to determine which flavors are associated with varying reinforcing and analgesic properties and how psychosocial stress affects the reinforcing properties of e-cigarettes. As part of Study Aim 3, researchers will test 75 adults (ages 18-45). Study findings may inform regulatory activities related to e-cigarette flavorings.

GSU TCORS: Testing Displays and Understanding of HPHCs

FDA is required by law to establish and make publicly available a list of harmful and potentially harmful constituents (HPHCs) in tobacco that is understandable and not misleading to the public. This study has two aims: (1) to determine how to best present information on HPHCs to consumers in a way that is understandable and not misleading, and (2) to test the relative effectiveness of different HPHC information formats by education level. In Aim 1, investigators will develop four visual formats to communicate information about the quantity of HPHCs in tobacco products. Each format will present information on the quantity of constituents selected from the list of HPHCs for which testing methods are established and widely available. The most simplistic of these formats will provide only numerical information listing the yields of constituents; the remaining formats will convey this information using visual or graphical presentations. Information about the health effects associated with each constituent will also be included. In Aim 2, investigators will evaluate the effectiveness of the four formats by testing them in a sample of 2,000 adult smokers (ages 18 and older), evenly split between low and high education level. Participants will be randomly assigned to receive one of the four formats or no information; participants will then complete a short survey about verbatim and gist knowledge of HPHCs, understandability of the information presented, and the extent to which the information presented might be misleading. Study findings may inform regulatory activities related to the development and public dissemination of an HPHC list.

Measurement of Nicotine Dependence among Adolescent and Young Adult Cigarillo Users

Cigar, cigarillo, and little cigar (CCLC) use increased 124% between 2000 and 2012. Adolescents and young adults are the most prevalent users; in some geographic areas, CCLC use now exceeds cigarette use among adolescents. Recent evidence shows that CCLC users inhale when smoking and that CCLC products contain as much or more nicotine than cigarettes. Therefore, assessing nicotine dependence among CCLC users is critical to understanding use behavior. Product-specific measures are needed to more precisely assess nicotine dependence, but no CCLC-specific nicotine dependence measures exist. The goal of this study is to establish a CCLC nicotine dependence symptom measurement tool that is relevant, valid, and reliable for use in adolescents (ages 13-17) and young adults (ages 18-38). Using an array of rigorous methods (including qualitative in-depth interviews with 40-60 participants, Rasch modeling for measure development, and survey and biomarker data), investigators will create and validate a measurement tool. The tool will then be administered to 1,000 adolescents using the National Youth Risk Behavior Survey to assess the prevalence of nicotine dependence symptoms among CCLC users. Study findings may inform regulatory activities related to CCLC products.

Effect of Packaging on Smoking Perceptions and Behavior: A Randomized Trial

The impact of cigarette packaging and labeling on consumer perceptions and smoking behavior and the effectiveness of graphic warning labels for communicating tobacco product risks are two critical topics warranting further study. In a randomized controlled trial, investigators will enroll 450 committed smokers (ages 21-50 years) who currently smoke at least five cigarettes per day and who have no intention of quitting in the next six months. Study aims are: (1) to test how standard tobacco industry imagery from U.S. cigarette packs influences consumer perceptions of their cigarettes; (2) to test whether adding large graphic warning labels increases perceptions of the harm of tobacco products; and (3) to test whether the Australian model packs result in a change in cigarette pack handling, consumption patterns, and quitting cognitions. For four months, participants will order their cigarettes on a secure study website and have them delivered within two days. Participants will be randomized to receive one of three types of cigarette packs: a) cigarettes repackaged in a plain pack, with the Surgeon-General’s warning labels but no tobacco marketing; b) cigarettes repackaged into the Australian-type pack (large graphic warning label, highlighted warning labels but no tobacco marketing) and c) a standard U.S. pack. During the course of the study, participants will: a) complete a web-based questionnaire; b) provide a saliva sample for cotinine analysis; c) undergo a laboratory-based motion sensor technology assessment that will measure pack handling and time interacting with warning labels; and d) participate in interactive messaging. Research findings may inform regulatory activities related to cigarette packaging and labeling.

Microbial Populations and the Development of Tobacco Specific Nitrosamines in Moist Snuff Products

Certain bacteria and fungi in tobacco may contribute to the development of tobacco-specific nitrosamines (TSNAs), which are cancer-causing substances in smokeless tobacco and other tobacco products. The goal of this study is to evaluate potential additional ways that TSNAs can be limited in smokeless tobacco products. Study aims are: (1) to determine whether there is a difference in the types of bacteria and fungi found in products purchased at different times of the year; (2) to compare the TSNA levels with the types of microorganisms present; and (3) to examine the impact of storage time and temperature on microbial populations and TSNA levels. Researchers will count cultured bacteria and fungi from moist snuff, identify unique strains using DNA sequencing, and evaluate these strains for their ability to reduce nitrate and nitrite, which are associated with TSNA development. Researchers will also analyze the total microbial DNA in snuff to determine the relative proportions of microorganisms present in the samples, and will screen them by polymerase chain reaction (PCR) for nitrate and nitrite reductase genes. Some bacteria and fungi can convert the nitrate in tobacco to nitrite, which then reacts with chemicals such as nicotine to yield TSNAs; thus, strains able to reduce nitrate and/or nitrite will be spiked into snuff to determine whether they affect TSNA development. Nitrosamine content in snuff samples will be measured by ultra-performance liquid chromatography and tandem mass spectrometry-based methods. Finally, researchers will evaluate the impact of storage conditions to determine the effects of time and temperature on microbial changes and TSNA production. The results should clarify the additional factors that contribute to TSNA development and identify additional conditions that can minimize the impact of TSNAs on user health, and thus may inform regulatory activities related to smokeless tobacco.

Analysis of Smokeless Tobacco Products for NNN

A chemical analysis of smokeless tobacco products to determine quantities of N’-nitrosonornicotine (NNN), a known tobacco product carcinogen, can aid FDA in the review and assessment of product reports that include  this reporting requirement.  This project will measure NNN quantities and moisture levels in 35 smokeless tobacco products currently marketed in the U.S. using a validated testing method. (Project completed in 2015.)

Comparison of TNCO Yields Generated by the ISO and a Modified ISO Smoking Regimen

Measurement of the quantities of tar, nicotine, and carbon monoxide (TNCO) in the mainstream smoke of cigarettes currently marketed in the U.S. will provide important information about these constituents. The purpose of this project is to determine the differences between TNCO yields generated under the smoking regimen defined by the International Standards Organization (ISO) and yields generated under a modified version of the ISO regimen. Researchers will test approximately 35 different cigarette brands using smoking machines using the ISO and modified ISO smoking regimens; researchers will determine whether there are differences in TNCO smoke yields between these two regimens.  (Project completed in 2015.)

UMD TCORS: Sweet Flavors in E-Liquids

Initial data indicate that e-cigarette flavors perceived as sweet are appealing to young adults and smokers trying to quit combustible cigarette smoking; however, little is known about how sweet e-cigarette flavors influence initiation, maintenance, and smoking cessation. There are also little data on the identity and amounts of the chemicals users inhale when using an e-cigarette flavor perceived as sweet. In this supplement to an ongoing study, investigators will measure the subjective responses (using sensory and hedonistic scales) to seven flavors of a popular commercial e-cigarette of 80 established e-cigarette users (ages 18 and older); participants will include both former and current combustible cigarette smokers. Investigators will then use standard liquid chromatography techniques and two-dimensional gas chromatography with time-of-flight mass spectrometry to analyze the e-cigarette liquids to identify and quantify the chemicals most likely associated with perceptions of sweetness, and will evaluate these compounds for toxicity. Finally, to determine how sweet flavors may be used to mask the bitterness of nicotine, investigators will quantify the sweet-associated chemicals across varying nicotine strengths to determine how levels of these compounds may change with changing nicotine level. Study results may inform regulatory activities related to e-cigarettes and flavors.

Impact of Flavors in Tobacco Products: An Experimental Market Analysis

The impact of flavors on the attractiveness and use of tobacco products warrants further study. The aims of this supplement to an ongoing study are: (1) to estimate the impact of flavors on tobacco product attractiveness and use in experimental markets in which low socioeconomic status (SES) adult tobacco users (ages 18 and older) will make choices between cigarettes, smokeless tobacco, little cigars and cigarillos, and e-cigarettes; and (2) to cross-validate the experimental market analysis through analysis of existing data on consumer purchases and retailer sales of cigarettes, smokeless, little cigars, cigarillos, and e-cigarettes in actual markets. To accomplish Aim 1, investigators will use a mobile laboratory to conduct discrete choice experiments with 500 low-SES adult tobacco users; participants will be asked to make purchase decisions under multiple scenarios in which the products stay the same but the products’ characteristics, such as flavors, vary. To accomplish Aim 2, investigators will analyze existing Nielsen consumer panel and retailer scanner data in several markets; investigators will then develop a model that predicts consumer product choices under different market conditions. Study findings may inform regulatory activities related to tobacco product flavors.

USC TCORS: Abuse Liability of Flavored E-Cigarettes with and without Nicotine

Data characterizing the variation in abuse liability across different types of e-cigarettes are scant. Flavoring in e-cigarettes is a critical dimension of product diversity that may modulate abuse liability. Young adults may be especially vulnerable to using sweet-flavored e-cigarettes. The goal of this supplement to an ongoing study is to evaluate the abuse liability of sweet-flavored e-cigarettes with and without nicotine in 30 young adult e-cigarette users (ages 18-35). Study aims are: (1) to identify the main effects of sweet flavored (vs. unflavored) e-cigarettes on abuse liability; (2) to identify the main effects of nicotine (vs. placebo) e-cigarettes on abuse liability; and (3) to identify the interactive effects of flavoring and nicotine on abuse liability. Participants will attend four laboratory sessions following 16-hour abstinence; all sessions will be identical except the study e-cigarette flavor/drug combination supplied in a particular visit will vary (flavored + nicotine [18 mg/mL]; unflavored + nicotine [18 mg/mL]; flavored + placebo [0 mg/mL]; unflavored + placebo [0 mg/mL]). At each visit, investigators will evaluate subjective and physiological abuse liability measures (e.g., mood enhancement, nicotine withdrawal suppression, food craving suppression, heart rate); participants will also complete an objective behavioral task to measure product reinforcement. Study findings may inform regulatory activities related to e-cigarette flavors.

The Role of Nicotine and Non-Nicotine Alkaloids in E-Cigarette Use and Dependence

E-cigarettes contain variable quantities of nicotine and non-nicotine tobacco alkaloids (NNTAs) (including anabasine, anatabine, nornicotine and myosmine), which are also present in conventional cigarettes. However, virtually no information is available concerning the role of e-cigarette nicotine or NNTA content in influencing the concurrent use of cigarettes and e-cigarettes (dual use); additionally, it is not known whether the presence of nicotine and NNTAs in e-cigarettes sustain dependence. This study will assess the effects of e-cigarette nicotine and NNTA content on 375 adult daily cigarette smokers (ages 18-65). Study aims are: (1) to assess the role of e-cigarette NNTA content in affecting dual use; (2) to assess the role of e-cigarette nicotine content in affecting dual use; and (3) to determine the relationship between dependence and systemic levels of nicotine and NNTAs. Participants will be randomized to one of three groups. Group 1 will use e-cigarettes that yield nicotine and NNTAs in the range of typical commercial cigarettes (e.g., 0.6 mg nicotine delivered in 10 puffs of 35 mL, with a ratio of NNTA to nicotine yield that is also typical of cigarettes). Group 2 will use e-cigarettes that contain minimal nicotine and NNTAs (less than 1/10 that of Group 1). Group 3 will use e-cigarettes that contain propylene glycol and extract from low nicotine/NNTA content tobacco (this group will control for changes in cigarette consumption that may occur due to study participation or to the non-nicotine behavioral/sensory factors associated with e-cigarette use, which could influence cigarette consumption). Dependence and dual use will be assessed according to: self-report diaries in which participants will track daily number of cigarettes smoked and number of occasions of e-cigarette use; cotinine concentrations and NNTA levels measured in urine, plasma, and saliva; various nicotine dependence, craving, and withdrawal measures; and tobacco abstinence after 12 weeks. Study findings may inform regulatory activities related to e-cigarettes.

E-Cigarettes: Dynamic Patterns of Use and Health Effects

E-cigarettes have been rapidly adopted in the U.S., but data on e-cigarette use and its effects are limited. This study will generate in-depth, long-term data based on real-time reports that will examine the relationship between e-cigarette use and: 1) nicotine dependence; 2) reductions in conventional cigarette use; 3) health-related indicators such as biomarkers of exposure, carcinogens, and acute and long-term pulmonary health; and 4) attempts to quit conventional cigarette use and the success of those attempts. Over two years, investigators will collect data from 150 adult smokers (ages 18 and older) who exclusively smoke conventional cigarettes and 250 adult dual users of e-cigarettes (ages 18 and older) and conventional cigarettes. Investigators will use ecological momentary assessment to determine: 1) changing patterns of e-cigarette and conventional cigarette use and related outcomes (e.g., dependence, withdrawal symptoms, reward value, conventional cigarette quit attempts and quitting success); 2) stable and episodic variables (e.g., lifestyle factors, demographics) that vary with e-cigarette and conventional cigarette use and related outcomes; and 3) targeted biomarkers of tobacco and carcinogen exposure as well as other health-related outcomes (e.g., pulmonary function). Investigators will analyze data gathered over time and will compare the dual use and conventional cigarette use groups. This study will yield information about patterns of real-world e-cigarette use and how such use is related to conventional cigarette smoking and associated health risks, and may inform future regulatory activities.

CTP Supplement to Parent Grant: Improved Models to Inform Tobacco Product Regulation

The impact of flavors and packaging of cigarettes, cigars, e-cigarettes, and smokeless tobacco are not well known. This supplement to an ongoing study will expand two projects of the University of California San Francisco Tobacco Center of Regulatory Science to include a focus on flavors and package characteristics. Study aims are: 1) to determine how flavors affect perceptions of risks, benefits, attractiveness and acceptability of tobacco products across age groups; 2) to determine how packaging characteristics affect perceptions of whether a product is flavored and perceptions of risks, benefits, attractiveness and acceptability of the product across age groups; 3) to determine the relationships among perceptions of flavored tobacco products and the onset, experimentation, continuation, cessation, relapse, re-initiation, switching, and dual/poly use of tobacco products including cigarettes, cigars, e-cigarettes, and smokeless tobacco; and 4) to determine the effect of flavors on the uptake, retention and rewarding effects of nicotine in users of second-generation e-cigarette devices. The project will collect the needed data by expanding the data collection in existing projects; data will be collected from urban and rural youth and from e-cigarette users who have been recruited to participate in studies of the dynamics of nicotine in the blood of e-cigarette users. Project expansions will extend the Center’s current research examining how flavor effects are mediated by psychosocial and bio-behavioral determinants. Study findings may inform regulatory actions related to tobacco product flavors and packaging.

CTP Supplement to Parent Grant: Fetal Behavior, Brain & Stress Response: Ultrasound Markers of Maternal Smoking

Maternal tobacco use during pregnancy is a significant public health problem. Pregnant women may be vulnerable to the appeal of tobacco product flavorings due to alterations in taste, cravings, nausea, as well as to variable patterns of tobacco use during pregnancy. In this supplement to an ongoing study, 50 pregnant smokers and non-smokers (ages 18-40) will complete detailed interviews and self-report measures regarding perceptions and use of flavors/flavored products. Study aims are: (1) to evaluate the impact of flavors/sweetness on perceptions and attractiveness of tobacco products in pregnant smokers and non-smokers, and (2) to evaluate the impact of perceptions of flavors/sweetness on use of flavored tobacco products in pregnant smokers and non-smokers. Study findings may inform regulatory activities related to tobacco product flavors.

Yale TCORS: Chemosensory and Physicochemical Factors in Flavor Sweetness of Tobacco Products

Flavors and sweeteners are present in most e-cigarette solutions and cigars/cigarillos, and are emerging as important determinants of use behaviors; thus, an understanding of how characteristics like smell, taste and constituents alter tobacco product perceptions is critical. This supplement to ongoing research conducted by the Yale Tobacco Center of Regulatory will combine systematic psychophysical measurements of sweet flavor perception and liking with detailed chemical analyses of the base constituents, flavoring and sweetener agents in e-liquids/vapors. The psychophysical measurements will be conducted on 60 adult smokers (ages 18-45) and will include subjective ratings of perceived sweetness, overall flavor intensity, irritation/harshness, and liking/disliking collected using computerized labeled magnitude scales Investigators will also conduct preliminary chemical analyses of the flavor/sweetener composition of cigars/cigarillos, which will be used to support future psychophysical experiments on these products. Study aims are: 1) to determine whether the vegetable glycerin/propylene glycol ratio in e-liquid bases affects the sweetness of e-cigarette flavors; (2) to determine how flavor additives interact to produce the perceived sweetness of e-cigarette liquids containing nicotine; (3) to conduct analytical characterizations of flavors, sweeteners, and nicotine in e-liquids and aerosols, and (4) to initiate exploratory characterizations of flavors and sweeteners in cigar/cigarillo wrapping papers. Study findings may inform regulatory activities related to flavors in e-cigarettes and cigars/cigarillos.

VCU TCORS: Evaluating Flavors in Novel Tobacco Products: A Transdisciplinary Approach

A model for predicting the harm or risk associated with potential modified risk tobacco products (tobacco products marketed with the claim that they reduce harm or risk associated with conventional products) is needed. This project, conducted by the Center for the Study of Tobacco Products (CSTP) at Virginia Commonwealth University, will extend CSTP’s evaluation model to examine the effects of tobacco product flavors and nicotine content on measures related to initiation and subsequent use in young adults. Specifically, the goal of this project is to evaluate the influence of e-cigarette flavor and nicotine content on user perceptions and measures of abuse liability. In one study, investigators will characterize the perceived effects of e-cigarette flavors by analyzing data gathered from 45 young adult e-cigarette users (ages 18-21) who report a history or preference for flavored (tobacco/menthol, fruit, and food/dessert) e-liquids; investigators will also examine the influence of preferred e-cigarette nicotine content. In a second study, investigators will examine the individual and combined effects of e-cigarette flavors and nicotine content on subjective measures of abuse liability among 28 young adult conventional tobacco cigarette smokers (ages 18-21). Results from the first study will inform the choice of specific flavors to be tested in the second study. Study findings may inform regulatory activities related to flavorings and nicotine content in e-cigarettes and other tobacco products.

The Time Course and Clinical Significance of Early E-cigarette Withdrawal Effects

Data on the time course and clinical significance of e-cigarette withdrawal do not exist, and therefore a complete understanding of the addictive nature of these products is unknown. This study will characterize the early time course, clinical significance, and moderators of e-cigarette withdrawal effects, and will compare the early withdrawal effects of e-cigarettes to those of tobacco cigarettes. Participants will include 150 e-cigarette users and 150 tobacco cigarette users (ages 18 and older); some participants may be exclusive users of their product. Baseline measures will include demographic characteristics, e-cigarette history and use characteristics, nicotine dependence, abstinence-related thoughts and expectations, and intolerance for abstinence discomfort. Participants will then participate in one of two experimental sessions: four hours of abstinence or use as usual. Withdrawal effects will be measured every 30 minutes, and will include negative affect (Wisconsin Smoking Withdrawal Scale), physical symptoms (Minnesota Nicotine Withdrawal Scale), multifaceted craving (Tobacco Craving Questionnaire), anhedonia (Tripartite Pleasure Inventory), perceived reinforcement value of smoking (Cigarette Choice Procedure), and open-ended report. At the conclusion of the four-hour period, participants will complete the Behavioral Smoking Lapse Analogue Task, a task that measures the ability to resist the temptation to use e-cigarettes or cigarettes under conditions in which it is advantageous to remain abstinent. Analyses will evaluate e-cigarette withdrawal effect differences between abstinent and non-abstinent sessions, test the relationships between e-cigarette withdrawal effects and Behavioral Smoking Lapse Analogue Task performance, and determine if withdrawal effects and Behavioral Smoking Lapse Analogue Task performance differ between e-cigarette and tobacco cigarette users and across baseline measures. Study findings may inform regulatory activities related to e-cigarettes.

Adolescent Rodent fMRI Model of Nicotine Dependence

A cingulate-striatal addiction circuit, a neurological connection in the brain that has been identified in humans who are addicted to tobacco (but not in tobacco users who are not addicted), has been developed for use as a rodent model of nicotine addiction. This project extends the pilot study that established this circuit in rodents by examining factors that could alter the development of addiction. The circuit will be evaluated using resting state functional connectivity MRI, an imaging technique that measures brain activity while the subject is not engaging in any particular task or activity. Since adolescence is the time of susceptibility to developing nicotine addiction, this project will examine the developmental trajectory of the circuit as a biomarker of nicotine addiction in adult versus adolescent rats. The impact of nicotine dose, age, and time course of nicotine exposure on circuit development and strength will be examined and analyzed in relation to the withdrawal/extinction time course. Specific aims are: 1) to compare the dose response range of nicotine exposure that elicits enhanced nicotine dependence in adolescent versus adult rats; 2) to identify the circuit strength associated with increased behavioral measures of nicotine dependence following adolescent rat nicotine exposure; and 3) to identify adolescent rat brain structure changes associated with enhanced behavioral measures of nicotine dependence. As a biomarker of addiction, this circuit may subsequently be used to investigate the abuse liability of various tobacco products and constituents, which could inform future regulatory activities.

Pharmacokinetic Analysis of Nicotine in Sprague-Dawley Rats

Accurately predicting nicotine uptake and disposition would be useful for assessing the dose-response effects of nicotine across organ systems. This study will: (1) establish data on nicotine distribution in rats following exposure through three different routes of administration (intravenous, oral, and inhalation), and (2) generate a mathematical model that determines the parameters of nicotine distribution, metabolism, and excretion in rats. The results of this study will aid in the understanding of nicotine disposition in blood and other tissues based on the route of administration and will inform model development.

Implementation of Evaluation Plan to Evaluate the City of Chicago Flavored Tobacco Ban Near Schools

The City of Chicago ban on the retail sale of all flavored tobacco products within 500 feet of elementary, middle or secondary schools went into effect in July 2014. Investigators at the Research Triangle Institute, the Institute of Health Research and Policy at the University of Illinois at Chicago, and the Chicago Department of Public Health will evaluate how this ban affects Chicago’s retail marketing environment. Specifically, investigators will assess the immediate (five weeks post-ban) and short-run (seven months post-ban) impact of marketing-related policies and how this impact varies by communities’ socio-economic, demographic and geographic characteristics. Study aims are: (1) to determine whether product availability, placement, promotion, and price of tobacco products have been affected by the ban, and (2) to determine whether the ban has affected the retail market for tobacco products in general. Investigators will collect data on flavored tobacco product availability, placement, promotion (i.e., advertising) and price post-implementation (5 weeks and 7-month follow-up) in 277 retail stores directly affected by the ban and two comparison groups: (1) 312 licensed tobacco retail outlets within 501-1000 feet of schools; and (2) 335 licensed tobacco retail outlets beyond 1000 feet of schools. Post-implementation data will be compared to baseline data (which was collected in May and June 2014). In addition to the store observations, investigators will interview 90 tobacco retailers and conduct focus groups with 40 youth (ages 14-17) in order to understand how the flavored tobacco ban impacts each of these populations. Study findings may inform potential regulatory actions regarding the sale of flavored tobacco products.

Implementation of Evaluation Plan of the NYC Ban on Non-cigarette Flavored Tobacco Products

The New York City ban on non-cigarette flavored tobacco products, which went into effect in October 2009, prohibited the sale of all non-cigarette flavored tobacco products in the city. This evaluation will focus on how the ban was implemented and whether implementation had the intended effects and/or yielded any unintended consequences. In particular, the evaluation will address the effects of the ban on retailers and consumers, exploring compliance with the law, sales of specific products, purchasing patterns, product use, and quitting behavior. The investigators will employ a multi-method approach, including the compilation and analysis of existing survey data as well as and the collection of newly-collected quantitative (e.g., retail observational studies) and qualitative (e.g., policy analysis, interviews with tobacco retailers and other stakeholders) data. Findings may inform potential regulatory actions regarding flavored tobacco products.

Enhancing Tobacco Surveillance through Online Monitoring

Epidemico, a research and informatics company, has developed a social media monitoring tool (MedWatcher Social) that mines online sources (e.g., Twitter, Facebook, online forums, blogs, electronic news sites, Internet searches) for information that can be used for a wide range of activities, including supporting drug safety surveillance and tracking disease outbreaks.  This project will expand that monitoring tool to provide new information about tobacco use, perceptions, attitudes and adverse health experiences reported by tobacco product users. Toward that end, Epidemico will develop unique acquisition and storage technology, mapping strategies, and algorithms to gather and classify data in social media, and will develop methods for analyzing and presenting this data. Research areas that may be explored include (1) examining time-related patterns in the volume of social media posts according to tobacco product type, brand, and subbrand; (2) describing social media posts related to the adverse health experiences of users of new products; and (3) describing feelings (positive/negative/neutral) associated with social media posts, including how feelings vary across tobacco product types, brands and subbrands. This project is intended to complement traditional methods of tobacco monitoring and surveillance by providing additional sources of information on tobacco use and related behaviors.

Behavior and Toxicant Exposure among Dual Users of Cigarettes and E-Cigarettes

Little is known about how dual use of traditional cigarettes and electronic cigarettes (e-cigarettes) influences measures of tobacco-related harm, including use patterns and toxicant exposure. The goal of this study is to evaluate measures of potential harm associated with dual cigarette and e-cigarette use. Specific aims are: (1) to evaluate changes in tobacco product consumption during dual use in comparison to single product use; and (2) to evaluate changes in toxicant exposure during dual use in comparison to single product use and no tobacco/nicotine use. Researchers will enroll 28 dual users of cigarettes and e-cigarettes aged 18-60 to complete four study conditions (dual use, cigarette-only use, e-cigarette-only use, and no tobacco/nicotine use), each lasting five days. Researchers will evaluate and compare conditions by measuring product consumption, toxicant exposure (i.e., carbon monoxide, cotinine, and total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL]), physiological data (i.e., heart rate, blood pressure), and subjective indicators related to nicotine effects and nicotine abstinence-related symptoms. Results may provide new information about whether dual use of cigarettes and e-cigarettes decreases, has little effect on, or increases measures of potential harm relative to single product use and no tobacco/nicotine use.

Cognitive Testing of Measurement Instruments for the Consumer Comprehension of Displays of Harmful and Potentially Harmful Constituents (HPHCs) in Tobacco Products Study

This qualitative study will gather information about different ways of presenting harmful and potentially harmful constituent (HPHC) information by brand and by quantity in a format that is understandable and not misleading to a layperson. Qualitative and in-depth interviews will be with a total of nine participants. Adult participants (aged 18 and older) will be current or former tobacco (cigarette and smokeless) users; youth participants (aged 14-17) will also include those who are susceptible to tobacco use. Topics covered in the interviews will include what participants know and perceive about HPHCs in tobacco products, how and in what formats do they prefer to receive information regarding HPHCs, and how they understand and perceive the information about HPHCs provided in four sample formats. Findings may inform regulatory activities related to the presentation of HPHC information.

Cognitive Testing of Cigarette and Snus Perception Items

Researchers will conduct cognitive interviews with eight tobacco users in May 2015 to test survey questions proposed for use in research on consumer perceptions, awareness, beliefs, and behaviors related to cigarettes and snus. The objectives of the cognitive interviews are: (1) to assess participants’ comprehension of survey questions; (2) to understand how new or revised questions affect the usability of existing surveys; and (3) to provide insights that may be used to improve the survey design as needed. Findings from these interviews will be used to inform the measurement of consumer perceptions, awareness, beliefs, and behaviors regarding tobacco use.

Cognitive Interviews with Adult E-Cigarette Users to Inform Label Development

The goal of this study is to conduct cognitive interviews with adult male and female e-cigarette users to inform the development of e-cigarette warnings. Nine participants will be interviewed in Philadelphia, PA. The interviewer will use a semi-structured guide to obtain participants’ reactions to and input on various e-liquid warning text and images describing the acute toxic effects of e-liquids.

Developing and Testing Warning Statements about E-cigarettes

Few research studies have explored whether smokers have concerns about the safety of e-cigarettes and whether such information might impact e-cigarette risk perceptions and use intentions. The goal of this project is to develop and test potential future warning statements for e-cigarette products and advertisements. Specific aims are: (1) to explore smokers’ perceptions of e-cigarette risks and potential warning statements; (2) to obtain feedback from tobacco control experts on potential e-cigarette warning statements; and (3) to examine the impact of different e-cigarette warning statements on smokers’ e-cigarette risk perceptions and use intentions. To accomplish Aim 1, researchers will conduct eight focus groups with adult smokers and e-cigarette users (four in-person and four online groups, 8-12 participants each, aged 18 and older) to explore their e-cigarette risk perceptions, learn their beliefs about whether e-cigarette products should carry warning labels, and obtain feedback on preliminary concepts for e-cigarette warning statements and ideas for alternative statements. To accomplish Aim 2, researchers will survey 50-75 tobacco control professionals with expertise in e-cigarettes and warning label research to obtain their feedback on warning statements. To accomplish Aim 3, researchers will randomly assign 600 adult smokers to view one of three potential e-cigarette warning labels and then survey participants about various attributes, including efficacy. Researchers will also use eye-tracking technology on 30 adult smokers to assess the potential impact of different warning sizes and placements. Research findings may help inform future regulation related to e-cigarette labeling and warnings and evaluation of e-cigarette communication messages.

Communicating Harm of New Tobacco Products

Despite significant gains achieved by public education campaigns, many people still underestimate the risks of tobacco use. The situation is compounded by aggressive marketing of new and alternative tobacco products, such as snus, dissolvables, and electronic cigarettes. The goal of this project is to determine effective ways to communicate the harm of tobacco products. Specific aims are: (1) to identify the key features (e.g., naming specific diseases, depicting affected body parts, listing harmful chemicals) of anti-tobacco messages with high informational and emotional ratings; (2) to compare the effects of “information only” and “information + emotion” messages on harm perceptions, use intentions, and attitudes toward tobacco control regulation; and (3) to determine how communication about cigarettes vs. new and alternative tobacco products impacts message processing and responses to anti-tobacco messages among different subpopulations (i.e., current smokers, former smokers, and non-smokers). To accomplish these aims, a total of 7,050 adult (aged 18 and older) current, former, and non-smokers will participate in five studies. Participants will be shown text- and image-based messages conveying the harms of established and new tobacco products and then complete a self-administered online survey evaluating emotion, informativeness, message efficacy, processing time, and other variables such as perceived harm and support for tobacco regulation. This research may inform the FDA’s policymaking and educational efforts related to new and established tobacco products.

Cognitive Testing of Tobacco-Related Questions and Concepts

Cognitive testing can reveal how consumers understand tobacco-related concepts and answer tobacco-related questions, and can inform the development and revision of survey questions and text. The cognitive testing in this study will involve one-hour, in-person, moderator-facilitated individual interviews with approximately 45 youth (ages 12-17) and adults (ages 18+)in which participants will be asked to answer and react to tobacco-related survey questions and text. The objectives of the interviews are: 1) to determine age appropriateness and reader comprehension of questions; 2) to understand how new or revised questions affect the usability of existing surveys and questionnaires; and 3) to provide insights that may be used to improve the questions and survey questionnaires. Newly-developed and/or existing survey questions involving tobacco product-related perceptions and behaviors will be tested; tobacco products covered will include chewing tobacco, cigarettes, cigarillos, dissolvables, modified risk tobacco products, new and emerging tobacco products, nicotine, snus, pipe tobacco, e-cigarettes, hookah/waterpipe, large cigars, little cigars, roll-your-own tobacco, and smokeless tobacco. This research may inform the development and revision of questionnaires used in experimental studies as well as national tobacco surveys.

Meta-Analysis of Psychological Measures Predicting Consumer Adoption of Tobacco and other Products

Identification of the best predictors of consumer adoption of new and emerging tobacco products will inform social science research involving these products. The goal of this project is to identify and evaluate the strongest and most valid predictors of consumer adoption of novel products. Data collection will involve a systematic review and meta-analysis focused on measures of perceived risk and other psychological determinants of behavior, and their association with consumer adoption. Data will be collected in two interrelated phases. The first phase consists of a systematic literature review. The second phase consists of coding, data entry and analysis of literature review findings. Study aims are: 1) to identify the best predictors of consumer adoption of novel products; 2) to identify the best item-level measurement techniques to determine consumer adoption predictors, and 3) to develop a manuscript for publication in a peer-reviewed journal By identifying predictors of novel product adoption, this study may inform future consumer-focused research and education initiatives and regulatory activities.

Evaluation of Very Low Nicotine Content Cigarettes in Adolescent Smokers

Reducing cigarette nicotine content to a non-addictive level could reduce smoking rates by making cigarettes less reinforcing. However, little is known about the effects of very low nicotine content (VLNC) cigarettes on adolescent smoking behavior. Specific aims are: (1) to compare the effects of cigarettes varying in nicotine content on abstinence-induced craving and withdrawal, risk perceptions, product acceptability, and demand for usual brand cigarettes; and (2) to compare the effects of cigarettes varying in nicotine content on measures of smoking behavior and toxicant exposure in adolescent smokers aged 13-18. To accomplish Aim 1, researchers will compare the effects of cigarettes varying in nicotine content (normal nicotine content [0.83 mg per cigarette], moderate and low nicotine content [0.28 mg, 0.10 mg per cigarette] and very low nicotine content [0.06 mg per cigarette]) on abstinence-induced craving and withdrawal, affect, risk perceptions, product acceptability, and demand for usual brand cigarettes in 78 adolescent daily smokers. To accomplish Aim 2, researchers will randomize 90 adolescent smokers to either receive VLNC cigarettes or normal nicotine content (0.83 mg) research cigarettes for three weeks. Researchers will conduct daily assessments of total cigarette use, craving, and withdrawal; weekly assessments of breath carbon monoxide levels, cigarette acceptability, risk perceptions of VLNC and normal nicotine content cigarettes, and demand for usual-brand cigarettes; and pre- vs. post-use measures of nicotine and toxicant exposure (cotinine and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL]). By illuminating how VLNC cigarettes affect real-world smoking behavior in adolescents, research findings may inform future policy decisions.

Center for Evaluation and Coordination of Training and Research in Tobacco Regulatory Science (CECTR)

This project establishes the Center for Evaluation and Coordination of Training and Research in Tobacco Regulatory Science (CECTR), formed as a joint effort by Westat and the Legacy Foundation’s Schroeder Institute for Tobacco Research and Policy Studies. CECTR — which will be staffed by tobacco scientists, evaluators, training developers, epidemiologists, analysts, and statisticians – will serve as an efficient infrastructure for providing scientific leadership and technical research expertise. CECTR’s specific aims are: (1) to accelerate knowledge sharing and innovation by facilitating collaboration and communication; (2) to increase the timely availability of tobacco regulatory science conceptual models, common measures, and other policy-relevant research tools; (3) to enhance the capacity of the research community to conduct more rapid and impactful tobacco regulatory science research by coordinating cross-disciplinary training of CTP-funded scientists and facilitating data sharing, analysis, and synthesis; and (4) to enhance the quality and innovativeness of tobacco regulatory science and expand research capacity through a rigorous evaluation process. Results will include sustained and significant improvements in tobacco regulatory science methods, standards and applications; development of a shared conceptual framework for tobacco regulatory science; and training of the next generation of tobacco regulatory scientists.

Novel Approach to Quantify Nicotinic Receptor Upregulation in Smokers

A reliable and minimally invasive biomarker of extended nicotine exposure could be useful in measuring changes in nicotine intake and evaluating reduced nicotine content tobacco products. The goal of this project is to evaluate the utility of nicotinic receptor (nAChR) upregulation in two types of white blood cells (granulocytes and lymphocytes) as a biomarker of extended nicotine exposure. Specific aims are: (1) to determine the minimum blood volume required for quantification of β2-containing and β4-containing nAChRs in granulocytes and lymphocytes; (2) to assess upregulation of β4-containing and β2-containing nAChRs in smokers’ granulocytes and lymphocytes; and (3) to assess the relationship between upregulation of β2-containing and β4-containing nAChRs in white blood cells and nicotine exposure, measured by nicotine intake per day and plasma cotinine level. To investigate these aims, researchers will analyze blood samples from 50 smokers and 30 nonsmokers aged 18-60. Study results may provide data indicating whether nAChR upregulation in white blood cells is a potential biomarker of extended nicotine exposure.

Nicotine Delivery from Novel Non-Tobacco Electronic Systems

Electronic nicotine delivery devices (ENDS) are novel products that electronically generate a nicotine-containing vapor that is inhaled by the user. Electronic cigarettes (e-cigarettes) are the most popular ENDS on the market, but various types and brands exist and are engineered differently, and thus vary in their nicotine delivery to the user. The goal of this project is to evaluate various e-cigarettes and to establish an evidence base for evaluating their potential for nicotine delivery. Specific aims are: (1) to measure the amounts of nicotine present in various brands and types of e-cigarettes as well as the nicotine yields in vapors generated by the devices; (2) to investigate the levels of nicotine delivered by e-cigarettes to the bloodstream compared to levels delivered by conventional cigarettes (in a group of 18 adult smokers aged 18 and older), and the effect of e-cigarette nicotine solution flavorings on puff topography and nicotine delivery (in a second group of 18 adult smokers aged 18 and older); and (3) to develop a machine smoking protocol for various types of e-cigarettes that reflect users’ puffing behavior and product characteristics. These findings may inform the development and implementation of e-cigarette quality standards and testing methods.

Emerging Product Perceptions and Use among African-Americans

African-American youth are at high risk of tobacco use. Of particular concern is a significant increase in their use of emerging products such as cigars and cigarillos and a high likelihood of multiple product use. The goal of this study is to evaluate their perceptions, attitudes, and beliefs regarding the health and social effects of tobacco products — particularly emerging and unregulated flavored (e.g., menthol, fruit, candy) products — and to determine whether these cognitive and affective factors are related to experimentation. Specific aims are: (1) to determine whether there are distinct classes of African-American tobacco users with shared patterns of tobacco use, and whether certain characteristics define high-risk groups; and (2) to evaluate the impact of marketing exposure, risk perceptions, attitudes toward tobacco products, and use of flavored products on use patterns. Researchers will recruit 560 African-American youth aged 14-18 who have ever tried a tobacco product. In the first phase of the study, researchers will conduct six focus groups (8-10 participants each) to gather information on awareness and perceptions of emerging tobacco products, advertisements, advertisement and product exposure, and sources of product information and perceptions. In the second phase, 500 youth will complete a 30-45 minute paper-and-pencil survey about tobacco-related behaviors (e.g., use, intentions, cessation), nicotine dependence, use and perceptions of tobacco products (including mentholated and flavored products), perceptions of health and social risks, and marketing exposure. Distinguishing patterns of tobacco use among African-American youth may inform strategies for prevention, cessation, and regulatory action that address tobacco consumption by this vulnerable population.

Development of Methods to Expose Cells in Culture to Volatile Chemicals

Tobacco smoke is a mixture of more than 7,000 chemicals, and more than 70 of them have been classified as carcinogens by the International Agency for Research on Cancer (IARC). Airborne particles and volatile chemicals from tobacco smoke have harmful effects on public health; as a result, it would be useful to develop standardized analytical procedures that can be used to evaluate the cell toxicity and gene toxicity potential of these chemicals. The goal of this study is to develop and demonstrate the reproducibility of a cell culture exposure protocol for aerosols and volatile chemicals. Study aims are: (1) to develop a test procedure for the mouse lymphoma assay (MLA) using cultured suspension cells, a smoking machine, exposure chambers, and whole cigarette smoke as the test material; and (2) to demonstrate the reproducibility of the MLA exposure conditions by conducting exposures with different concentrations of whole smoke over a period of six months. The standard gene toxicity assay procedures will generate data to help determine the risks associated with exposure to aerosols and volatile chemicals in tobacco smoke.

Preliminary Study for Whole Smoke Acute Exposure in Lung Cells

Tobacco use can cause toxic damage to cells that can be identified by in vitro models. Using these models in conjunction with “omics” technologies may lead to the identification of biomarkers of harm associated with tobacco product use. The goals of this study are: (1) to test smoking machine performance using Kentucky reference cigarettes that are smoked under different smoking conditions, and (2) to develop an exposure model using human bronchial epithelial cells. A general cell toxicity test (lactate dehydrogenase release) will be used to assess the adverse effects caused by whole tobacco smoke at different concentrations and over time. Researchers will measure total particulate matter, total carbon monoxide, and nicotine yield of Kentucky reference cigarettes. Study results may be used to design subsequent “omics” studies.

Ecological Momentary Assessment (EMA) and Laboratory Assessment of Nicotine Dependence among Dual ENDS

Electronic cigarettes (e-cigarettes) are available in two types: “ciga-like” models that resemble cigarettes and “pen-like” models, which may be preferred by exclusive e-cigarette users because they can deliver more nicotine per puff, are customizable, and offer a better “throat hit” than ciga-like models. More information about how e-cigarette characteristics affect whether cigarette smokers transition from e-cigarette experimentation to habitual exclusive use, use both e-cigarettes and regular cigarettes, try and abandon e-cigarettes in favor of continued cigarette smoking, or stop using all tobacco products including e-cigarettes would enhance our knowledge about these products. Specific aims are: (1) to compare how measures of abuse liability (i.e., plasma nicotine concentration, subjective effects including craving and satisfaction, behavioral reinforcement) and measures of product appeal (i.e., perceived norms and liking, design, packaging) vary by e-cigarette device type; (2) to contrast the differences in abuse liability and measures of product appeal between usual cigarette brand and e-cigarette device; and (3) to examine the extent to which measures of abuse liability predict e-cigarette use at one, three, and six months. Researchers will randomize 128 current smokers aged 18-65 who have never used e-cigarettes but are curious about them to use either ciga-like or pen-like e-cigarettes during four laboratory visits over 8-12 days; visits will include assessment of plasma nicotine concentration and subjective ratings linked to abuse liability and product appeal. Research findings related to the differential effects of ciga-like and pen-like e-cigarettes on e-cigarette experimentation and subsequent use patterns may inform future regulatory actions.

Beta2 Nicotine Receptor Subunits: Biomarkers for Dependence

Nicotine dependence is the tobacco-related disorder that underlies tobacco-related diseases. Ongoing exposure to nicotine produces upregulation of beta2 nicotinic acetylcholine receptors (nAChRs), which is associated with nicotine dependence. Menthol may increase nicotine dependence by affecting neurons, increasing nicotine absorption through airway epithelium, and/or decreasing the breakdown of nicotine. The goal of this project is to develop a production-level assay for determining the upregulation of beta2 nAChRs in a mouse model. Specific aims are: (1) to develop an efficient, quantitative, low-resolution approach based on the immunoblot technique (“western blots”) for quantifying the amount of beta2 subunits in various regions of mouse brain; (2) to develop a higher resolution, semi-quantitative approach based on fluorescence that identifies the neuronal cell types and the subcellular regions where upregulation occurs; and (3) to use these tools to test the hypothesis that menthol upregulates nAChRs even when delivered intravenously. Establishing a biomarker for nicotine dependence in mice, and then using this biomarker to investigate menthol’s actions, may contribute to tobacco-related research activities.

Econometric Research on Regulating Menthol Cigarettes and Smoking Cessation

An estimated 18.1 million U.S. adults, or about 30% of adult smokers, smoke menthol cigarettes. Some evidence suggests that the availability of menthol cigarettes increases the number of smokers, partly by reducing cessation. The goal of this project is to use econometric methods to study relationships between menthol cigarette use and smoking cessation. Specific aims are: (1) to study the relationship between menthol cigarette use and smoking cessation; (2) to investigate the economics of consumer choices about menthol cigarettes and smoking cessation; and (3) to investigate the economics of consumer choices about menthol cigarettes over the life course. To accomplish Aim 1, researchers will analyze data from the 2003, 2006-07, and 2010-11 cycles of the Tobacco Use Supplements to the Current Population Survey (TUS-CPS) and data from the Simmons National Consumer Survey (NCS) from 1995 onward, which together provide data on nearly 80,000 current and past-year smokers. To accomplish Aim 2, researchers will use geocode information to merge the individual-level data from the TUS-CPS and NCS with market-level demand influences (e.g., price and advertising), and will use information on respondents’ magazine-reading habits to create individual-level measures of potential exposure to cigarette advertisements. This will enable researchers to investigate the extent to which smokers perceive menthol and non-menthol cigarettes to be close substitutes and evaluate the role of advertising in consumer choices. To accomplish Aim 3, researchers will use TUS-CPS data (e.g., ever use of menthol cigarettes; whether smokers used menthol cigarettes all or nearly all, most, half, or less than half the years they smoked) to build approximate lifetime histories of menthol use. By evaluating the impact of menthol use on smoking cessation, this research may inform regulatory actions related to menthol.

Assessment of the Addictive Potential of Cotinine, Anatabine, and Myosmine in Rodents

Although nicotine is the primary addictive constituent in tobacco, studies indicate that tobacco also contains non-nicotine constituents (including, but not limited to, anatabine, cotinine, and myosmine) that may have addictive potential.  Previously, researchers used a locomotor activity paradigm to determine behaviorally-active dose ranges of anatabine, cotinine, and myosmine for use in future studies of abuse liability. In this study, the researchers will use that previously-generated data to conduct pharmacological and behavioral studies in adult and adolescent rats to determine the addictive potential of these three constituents and highlight potential differences between adults and adolescents. The rats will be tested using three models of abuse liability — conditioned place preference, withdrawal signs, and central nervous system activity – that were identified based on acceptable measures of abuse liability used to include constituents on FDA’s harmful and potentially harmful constituent (HPHC) list with an addiction indication. Three doses of each constituent (selected based on the previous research results) will be tested in each paradigm; each does will be tested in 10 rats.  Midbrain dopamine release via in vivo microdialysis will be used to assess effects on central nervous system activity, and nicotine will be used as a positive control in all assessments.  The projected timeframe for completion of these studies is 1.5 years. By identifying tobacco constituents with addictive potential, study results may be used to inform product review or other regulatory activities.

Optimizing Graphic Warning Labels to Promote Cessation among Young Adult Smokers

Young adult smokers are susceptible to tobacco industry marketing and have a high risk of becoming lifelong smokers. The goal of this study is to examine whether two potential cigarette packaging regulations — requiring graphic health warning labels on cigarette packs and requiring plain (unbranded) packaging — reduce cigarettes’ appeal and lead to cessation. Specific aims are: (1) to determine whether graphic warning labels reduce the likelihood of cigarette purchases and to identify the factors that enhance this effect; (2) to investigate the short-term impact of warning message framing and plain packaging on the motivation to quit or reduce smoking; and (3) to assess the long-term durability of the effects of warning message framing and plain packaging. The study will involve a sample of 400 young adult smokers aged 18-30. First, participants will be shown cigarette packs that vary based on warning message framing (gain- or loss-framed) and packaging (branded or plain) and will be asked about their preferences regarding cigarette purchases based on the packs. Second, participants will be randomized to either use their regular cigarette packs or one of four adapted packs that contain their own cigarettes but vary based on message framing and packaging; all participants will respond to daily mobile phone text message prompts assessing motivation to quit and cigarettes smoked per day for four weeks and will complete an in-person final assessment. Finally, researchers will examine the durability of the effects of the adapted packs by assessing motivation to quit, cigarettes smoked per day, quit attempts, and pack-related behaviors (such as hiding the pack) one and three months after the study’s conclusion. Study results may inform regulatory policies related to cigarette packaging.

Perceptions of E-Cigarettes and Effects on Craving, Withdrawal, and Smoking Severity after Exposure to Virtual Reality Cues

Little is known about the behavioral, physiological, and neurobiological effects of e-cigarettes on smokers, particularly with regard to craving and withdrawal. An important target for investigation is how effective e-cigarettes are in alleviating cravings when smokers are exposed to smoking-related stimuli. Smoking cues (e.g., sight and smell of cigarettes, smoking environments, emotional states) often lead to intense episodic spikes in craving, which in turn can lead to smoking. The goal of this research is to assess smokers’ reactions to virtual reality cues — photo-realistic and interactive environments closely resembling situations in which participants are likely to smoke in the real world. Researchers will evaluate changes in craving, smoking severity, and withdrawal symptoms in 90 cigarette smokers aged 18-55 who have never used e-cigarettes following use of either an e-cigarette or their own (preferred) cigarette brand on three separate laboratory visits. Specific aims are: (1) to evaluate the effects of e-cigarettes (0 or 18 mg) or own cigarettes on virtual reality-induced craving, perceptions, and withdrawal symptoms; (2) to evaluate the physiological effects produced by nicotine obtained by smoking e-cigarettes or own cigarettes; and (3) to evaluate the effects of e-cigarettes or own cigarettes on smoking severity (i.e., increased latency to first cigarette, fewer cigarettes chosen, puff duration, puff volume). Information generated about whether e-cigarette exposure affects smoking severity by altering craving, withdrawal, and physiological responses may be used to inform regulatory actions.

Neural Markers of Use and Perception of E-cigarettes among Cigarette Smokers

Little scientific data are available on the effects of e-cigarettes on the brain. A non-biased biological tool such as brain imaging could provide important new information about the effects of acute e-cigarette exposure and smokers’ perceptions of these devices. The goal of this study is to use functional magnetic resonance imaging (fMRI) to study the different effects that regular and e-cigarettes have on the reward system in the brains of 90 cigarette smokers aged 18-55 who have never used e-cigarettes. Specific aims are: (1) to determine if use of e-cigarettes and regular cigarettes have similar effects on activation of the brain’s reward system; (2) to determine if perceptions of e-cigarettes and Surgeon General warnings affect brain activity during a picture-viewing experiment; and (3) to determine whether the reward activity and neural perceptions measured in Aims 1 and 2 are associated with changes in cigarette use and e-cigarette perceptions, satisfaction, and acceptability. By providing new information about the association between reward system activation and perceptions of regular and e-cigarettes, study findings may be used to inform regulatory activities related to e-cigarettes.

Unjust Targeting: How Marketing Features Impact Consumer Response and Tobacco Use

Certain “high impact” tobacco marketing features (e.g., colors, descriptors, branding, marketing claims) may be effective in appealing to particular ethic groups and thus may produce inequitable outcomes in tobacco use. The goal of this project is to connect tobacco marketing features with consumer affective, cognitive and physiological responses to marketing images, product perceptions, and use outcomes in ethnically diverse populations. Specific aims are: (1) to describe tobacco marketing features targeted towards African Americans, Asian Americans, Latinos, and non-Hispanic whites; (2) to identify how marketing features impact responses to ads among Latinos and Latino subgroups (e.g., Mexican American, Puerto Rican, Dominican, Central American, South American); and (3) for each ethnic group, to demonstrate how people initiate and change tobacco product use as a result of advertising awareness and to identify marketing features associated with product use. To accomplish Aim 1, researchers will link tobacco marketing data from the Population Assessment of Tobacco and Health (PATH) study to data from a PATH ad-hoc study of tobacco marketing images in order to identify which ads appeal to each ethnic group and to generate an inventory of high-impact marketing features for each product. To accomplish Aim 2, researchers will conduct online and laboratory-based studies with 1,100 subjects aged 18-24; the researchers will manipulate ad features in order to investigate which features most impact product perceptions and use intentions. To accomplish Aim 3, researchers will link PATH study data to data from the PATH ad hoc study to determine which ads have the greatest impact on tobacco use over time in each ethnic group and to identify the marketing features associated with ad effectiveness. By identifying the key marketing features that impact consumer responses and connecting those responses to tobacco use outcomes over time, project findings may be used to inform regulation regarding tobacco marketing.

Cancer Center Support Grant: Impact of Cigar Product Characteristics on Young People’s Cigar Use and Perceptions

While cigarette consumption in the United States is declining, cigar consumption has more than doubled since 2000. Cigar product and marketing characteristics (including flavorings such as fruit, candy, and alcohol) may increase cigars’ appeal to young people, but data on the extent to which cigar product and marketing characteristics influence use are limited. The goal of this project is to explore the impact of product features such as brand, flavor, and packaging on young adults’ cigar initiation, use, and perceptions. Specific aims are: (1) to understand consumer perceptions of cigar features; and (2) to examine the impact of cigar packaging features on consumer perceptions. Researchers will conduct semi-structured interviews with 40 cigar smokers aged 18-30 to understand their reasons for using cigars and assess their perceptions of product characteristics (e.g., flavor, packaging). Qualitative findings will be used to inform the development and implementation of a nationally-representative population-based Internet survey of approximately 800 past-year cigar smokers aged 18-30. In this survey, participants will be randomly assigned to one of 12 cigar pack conditions (2 brands x 3 flavors x 2 packaging types) and asked to rate the product on a number of consumer perception measures. As a secondary research effort, researchers will analyze national Nielsen market data from 2008-2014 to better understand the impact of product features on cigar sales; researchers will evaluate attributes such as type, brand, flavoring, size (e.g., little cigar or cigarillo), packaging, and promotions (e.g., buy-one-get-one-free) and calculate their impact on total sales, market share, and contribution to overall cigar growth. Research findings will provide information about the impact of cigar product and marketing characteristics on initiation, use, and perceptions, and may inform regulatory activities related to cigars.

Exploratory Study on the Effect the Format of Moist Smokeless Tobacco (Loose vs. Portioned) has on the Use Behaviors, Nicotine Exposure and Tobacco Dependence in Current Users

Use patterns may be different for portioned and loose (non-portioned) smokeless tobacco (ST) products; depending upon type of product used, users may alter their use behavior along measures such as frequency of use (e.g., mean use per day, total use per day), deposition time in the mouth, and amount of product used per occasion. Such changes in use behavior may affect nicotine exposure. However, little is known about the relationship between type of product, use behavior, and resulting nicotine exposure. The primary aim of this study is to investigate the behavioral aspects of ST use among users of loose and portioned moist ST products.  Endpoints of interest include amount used, deposition time in the mouth, and frequency of use. This study will also characterize differences in nicotine exposure from normal use of loose or portioned ST products and investigate the potential for nicotine dependence among adult moist ST product users (ages 18-65). Investigators will enroll 30 adult users of portioned ST and 30 adult users of loose ST for a one-day study session to evaluate the way they use the ST product and the resulting nicotine exposure. In addition, subjects will be administered a number of questionnaires to evaluate their ST dependence.  This study will provide new information about comparative ST use patterns and nicotine exposure that may be used to inform regulatory activities.

/Metals in Electronic Cigarette Aerosol

A number of metals and elements in electronic cigarette (e-cigarette) aerosol – such as lead, chromium, iron, strontium, and aluminum – are known carcinogens, respiratory toxicants/irritants, reproductive and developmental toxicants, or have other human health effects. The goal of this project is to identify and quantify the metal content of e-cigarette aerosols generated by a variety of products and designs, to examine the cytoxicity (i.e. toxicity to cells) and genotoxicity (i.e., toxicity to genetic information within cells) of aerosols with metal content, and to examine biomarkers of metal exposure and effects in users. Specific aims are: (1) to identify and quantify the metals in the fluid and aerosol of a broad range of e-cigarettes from different manufacturers and of different styles; (2) to use an embryonic model and a three-dimensional adult lung air-interface model to evaluate the cytotoxicity and genotoxicity of aerosols from products that contain metals; and (3) to measure biomarkers of metal exposure and effects in e-cigarette users by comparing 75 adults aged 21-40 who use e-cigarettes only, conventional cigarettes only, or no tobacco products, by analyzing metals in oral cavity cells and metal concentrations in saliva, blood, and urine. Research findings may inform regulatory policies related to e-cigarettes.

Alternative Tobacco Products: Use, Adverse Effects, and Communication Patterns; Adverse Effects of Mainstream Tobacco-Based Hookah Smoke in Young Adults

The health effects of waterpipe (hookah) tobacco use are not fully understood. Of particular concern is the common misconception that inhaling hookah smoke is less harmful than inhaling cigarette smoke because it is “filtered” through water. The goal of this clinical exposure study is to evaluate whether the inhalation of mainstream tobacco smoke generated by hookah smoking produces changes in the cardiopulmonary system that could result in acute and chronic adverse health effects. Specific aims are: (1) to ask current hookah users to smoke hookah in a clinical setting and then to characterize the exposure concentrations of particulate matter, carbon monoxide, black carbon, elemental and organic carbon, carcinogenic agents, and trace elements; and (2) to examine cardiopulmonary changes and inflammatory markers of tobacco exposure. To accomplish these aims, researchers will recruit 40 healthy young adults aged 21 to 30 who are current hookah smokers to smoke hookah tobacco in a controlled clinical setting. Researchers will measure a variety of indicators, including changes in pulmonary function (e.g., forced vital capacity, forced expiratory volume), cardiovascular function (e.g., blood pressure, heart rate, blood cotinine levels), airway epithelial cells, and blood and exhaled breath condensate markers of inflammation. Researchers will also evaluate the chemical composition and carcinogenic components of particulate matter and gases in mainstream hookah smoke. Research findings may be used to inform regulatory actions related to waterpipe tobacco.

Alternative Tobacco Products: Use, Adverse Effects, and Communication Patterns; Patterns of Communication and Information Transfer among Hookah Users

Little is known about what factors could lead to initiation and maintenance of hookah (waterpipe) use. The goal of this project is to assess risk perceptions, attitudes, and beliefs about waterpipe tobacco smoking, use intentions, and patterns of use among a diverse population of young adults, and to explore the nature and extent of communication about waterpipe tobacco. Specific aims are: (1) to study a diverse urban population of young adults and measure the percentage of respondents who either currently use waterpipe tobacco or are likely to start using it in the near future; and (2) to assess how hookah users gather and share information about waterpipe smoking. To accomplish these aims, researchers will conduct a cross-sectional Internet survey of a representative sample of 1,500 young adults aged 18-30 who are full- or part-time students at the City University of New York. Survey questions will address use history, knowledge, beliefs, attitudes, and communication patterns related to waterpipe tobacco. Next, researchers will conduct 12 focus groups (8-10 participants each) with a subset of survey respondents in order to explore beliefs, attitudes, and communication patterns regarding waterpipe tobacco smoking in more detail. Eight focus groups will include current waterpipe tobacco users and four will include people who do not currently use waterpipe tobacco but report a high intention to use it in the next six months. After the focus groups, researchers will code each participant’s use of social media to track communication about hookah use. Study findings may inform regulatory actions related to waterpipe tobacco. 

Do Electronic Cigarettes Reduce Harm?

Relatively little is known about the health effects of electronic cigarettes (e-cigarettes). The goal of this project is to understand how e-cigarettes affect human health by evaluating the cytoxicity (i.e. toxicity to cells) and genotoxicity (i.e., toxicity to genetic information within cells) of e-cigarette aerosols, flavorings, and chemicals. Specific aims are: (1) to quantify and compare the cytotoxicity and genotoxicity of mainstream smoke from established cigarette products with e-cigarette aerosols by analyzing effects on embryonic and differentiated human cells; and (2) to identify the chemicals that cause cytotoxicity and genotoxicity in the products tested in Aim 1. Research findings may be used to inform policies for regulating e-cigarettes.

Dual Cigarette and Smokeless Tobacco Use: Behavior Patterns and Toxicant Exposure

Many smokers have become “dual users” of both cigarettes and smokeless tobacco (SLT). The goal of this project is to understand how smokers’ health risks are affected as a result of dual use by characterizing their natural patterns of tobacco use. Specific aims are: (1) to determine whether cigarette smokers alter their smoking behavior on days when they also use SLT; and (2) to profile the patterns of SLT use among cigarette smokers within and across days. Researchers will study 120 adult smokers who also use SLT aged 18-55 for two weeks to determine their patterns of dual use of cigarettes and SLT. Participants will use electronic diaries to record various behaviors, contextual factors, and subjective experiences; they will also provide saliva samples so that cotinine levels can be analyzed to determine daily levels of nicotine exposure. Researchers will compare cigarette use on single (cigarettes only) versus dual use days, and will evaluate dual use as a function of various factors including indoor vs. outdoor activities, other drug use (i.e., caffeine, alcohol), type of SLT product used, mood, SLT use motivations and beliefs, and nicotine/tobacco craving level. Study results will shed light on whether cigarette smokers’ use of SLT is consistent with product supplementation or replacement, and thus how SLT use influences exposure to nicotine.

Measure Acrolein in Bidis and Little Cigars

A chemical analysis can inform the evaluation of the harmful and potentially harmful constituents (HPHCs) present in the mainstream smoke produced from little cigars and bidis. The goal of this project is to measure acrolein quantities in little cigar and bidi smoke using a variety of little cigar and bidi tobacco products currently marketed in the US. A total of 15 little cigar products and one bidi product will be examined under both the International Organization of Standardization (ISO) and Canadian Intense (CI) smoking regimens.  The results may be used to inform HPHC-related regulatory activities.

Evaluating the Toxicity and Inflammation Produced by Cigarette Smoke using Human In Vitro Airway Models

Traditionally, tobacco smoke toxicity has been evaluated with cell cultures grown on plastic surfaces using laboratory tests that are not specifically designed to measure smoke toxicity in the human respiratory system. In recent years, air-liquid-interface (ALI) airway tissue models derived from human bronchial epithelial cells have been developed that have many of the complex structural and functional properties of human airway epithelium. In this study, researchers will use a human airway ALI tissue model to evaluate the toxicity of cigarette smoke generated from University of Kentucky reference cigarettes using both the International Organization for Standardization (ISO) and Canadian Intense (CI) smoking machine protocols. The goal is to use an in vitro system having properties similar to the intact human airway to assess and compare the adverse respiratory health effects of tobacco smoke produced under different smoking conditions. The resulting data on airway-related outcomes may inform future regulatory actions related to products claimed to be equivalent or “modified risk.”

High-Throughput Screening Tobacco Constituents for Addiction Potential Using Docking of Nicotinic Acetylcholine Receptors

More than 8,000 chemicals identified in tobacco products and smoke have not been thoroughly evaluated for their potential to cause addiction. One of the mechanisms of addiction is nicotine binding to nicotinic acetylcholine receptors (nAChRs). In humans, two nAChR subtypes (α4β2 and α7) are most commonly found in the central nervous system; thus, chemicals that bind to α4β2 and α7 have potential to cause addiction. However, experimentally measuring the nAChR binding affinity of all tobacco constituents is difficult, if not impossible; thus, efficient screening methods for evaluating the addiction potential of these constituents are needed.  In this project, researchers will develop three-dimensional computer simulations of α4β2 and α7 structures; using these simulations, researchers will then screen more than 8,000 tobacco constituents in order to estimate their nAChR binding affinity (and, thus, their potential to cause addiction). The results will be presented as a database of tobacco constituents and their addiction potential estimates. Project results may be used to inform regulatory decision making or to select chemicals for laboratory testing.

Interactions between Tobacco Smoke Constituents in Rodent Tumor Models

Tobacco smoke is a complex mixture of chemicals, many of which are toxic and carcinogenic. However, it is unclear how individual components of the mixture interact to trigger cancer. Reducing the levels of one chemical may not reduce the overall carcinogenic properties of the tobacco product if the interaction between chemicals amplifies the effects of residual carcinogen levels. The goal of this project is to characterize the potential interactions between known human carcinogens (4-methylnitrosoamino-1-(3-pyridyl)-1-butanone [NNK], N’-nitrosonornicotine [NNN], and benzo[a]pyrene [BaP]) and volatile components of tobacco smoke (acetaldehyde, acrolein, and formaldehyde) in established rodent tumor models. Specific aims are: (1) to determine if acetaldehyde influences the carcinogenic properties of NNN in a rat esophageal tumor model; (2) to determine if inhaled aldehydes (i.e., formaldehyde, acetaldehyde, acrolein) modulate the carcinogenic properties of NNK in a mouse lung tumor model; and (3) to determine if inhaled aldehydes modulate the carcinogenic properties of BaP in a mouse lung tumor model. These studies may provide important new information about the ability of volatile compounds to influence the tumor-related activity of tobacco carcinogens, and may be used to inform product regulation.

Menthol: An Accomplice of Nicotine in Tobacco Smoking

A fundamental question regarding menthol, a tobacco product additive that causes a cooling sensation, is whether it directly enhances the reinforcing effects of nicotine and thus promotes tobacco addiction. The goal of this project is to conduct behavioral tests in rats to examine whether menthol promotes the initiation, maintenance/progression, and relapse to nicotine self-administration without the involvement of its sensory effects. Specific aims are: (1) to examine whether menthol promotes the initiation of nicotine self-administration; (2) to examine whether menthol facilitates the transition to greater nicotine self-administration; (3) to examine whether menthol facilitates nicotine-seeking behavior; and (4) to examine interactions between menthol and nicotine in the release of dopamine in the nucleus accumbens, a region of the brain’s reward circuit. Project results may inform regulatory policies related to the use of menthol in tobacco products.

Understanding E-Cigarette Adoption and Marketing: A Social Media Study

Although the e-cigarette research literature is growing steadily, a more detailed understanding of e-cigarettes’ health risks, their efficacy for smoking reduction and/or switching, and the marketing practices of e-cigarette vendors is required. The goal of this project is to use a social media data mining and analytics approach to gather comprehensive data related to e-cigarettes, including reasons for use, health effects, efficacy as a smoking reduction and/or switching aid, and industry marketing and promotional efforts in the U.S. Specific aims are: (1) to develop a continuously-updated dataset containing a significant portion of e-cigarette-related social media content and user social networking activities; (2) to understand the reasons for and health consequences of e-cigarette use (including efficacy as a smoking reduction and/or switching aid) as reported in social media; (3) to understand how e-cigarette vendors conduct social media-based marketing campaigns and evaluate responses in social media; and (4) to develop and evaluate a social media-based informatics platform for e-cigarette regulatory research. The results of this research project may inform tobacco-related regulatory activities related to e-cigarettes.

Constitutional Compliance, Credibility, and FDA-Regulated Tobacco Warning Labels

As groups at high risk of smoking, youth under age 18 and adults with low socioeconomic status (SES) are two main targets of tobacco control efforts. The goal of this project is to examine which variations of FDA-regulated health warnings are most effective for youth and low SES adults by testing various message strategies. Specific aims are: (1) to test message effectiveness by manipulating message elements (such as full color images and warning size) and to identify the elements capable of maintaining or increasing message effectiveness; and (2) to test strategies such as including third-party sponsorship on warning labels in order to increase perceptions of credibility and varying warning label language . To accomplish these aims, researchers will conduct seven randomized controlled experiments with a total of 3,840 participants by traveling in a mobile laboratory to locations where vulnerable populations reside. Populations studied will include: (1) low SES adult smokers over age 18 from rural communities (primarily Caucasian), (2) low SES pre-teens aged 11-13 from rural communities (Caucasian non-smokers), (3) low SES inner-city adult smokers over age 18 (Caucasian, Black, and Hispanic), and (4) low SES inner-city pre-teen non-smokers aged 11-13 (Caucasian, Black, and Hispanic). By using eye-tracking technology and evaluating participant reactions to various advertisements and packages with manipulated elements (e.g., color, images, language), researchers will measure attention to specific message attributes, message recall, health risk beliefs, perceived message effectiveness, intentions to smoke and to quit, emotional reactions, perceived message credibility, cognitive appraisal, self-efficacy, and message preference. Study findings may provide new information about how to design messages that achieve maximum effectiveness.

Comparative Transcriptomic Signatures of Inhaled Tobacco Smoke

Tobacco smoke exposure results in a significantly increased lifelong risk of numerous inflammatory lung diseases. While the health risks of tobacco smoke exposure are widely appreciated, there are no existing in vitro tests to ascertain the risks associated with exposure to different types of tobacco products. Hypothetically, reliable changes in gene expression can serve as biomarkers of tobacco smoke exposure that can predict human disease risk. The goal of this project is to detect specific disease-relevant gene expression signatures of smoke exposure from cigarettes, e-cigarettes, flavored little cigars, and hookah (waterpipe). Specific aims are: (1) to conduct comprehensive gene expression profiling of cell responses to different doses and types of tobacco and to develop assays that report tobacco smoke exposure; (2) to use animal models to define physiological responses to the inhalation of specific tobacco types and doses; and (3) to assess the human disease relevance of specific gene expression biomarkers. The proposed studies will generate an extensive database describing comprehensive gene expression responses to tobacco smoke exposure. This database may be used to develop assays that quantitatively and qualitatively measure the adverse impact of tobacco smoke exposure.

Pregnancy Risk Assessment Monitoring System (PRAMS)

Limited information is available about the use of new and non-traditional tobacco products during pregnancy and the impacts of these products on mother and baby health. To better understand the use of e-cigarettes and waterpipes during pregnancy and during the first three months preceding pregnancy, as well as the impacts of these products on birth and infant outcomes, questions about e-cigarettes and waterpipes will be added to the next phase of the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS, a surveillance project of the Centers for Disease Control and Prevention (CDC) and state health departments, enrolls women who have had a recent live birth, with each participating state sampling 1,300-3,400 women per year. Topics addressed in the PRAMS questionnaire include barriers to and content of prenatal care, obstetric history, maternal use of alcohol and cigarettes, physical abuse, contraception, economic status, maternal stress, and early infant development and health status. New questions about e-cigarette and waterpipe use will address frequency of use, use behaviors, and dual use of e-cigarettes and traditional cigarettes. Data generated by these new questions will help researchers evaluate tobacco product use patterns during pregnancy and will increase the understanding of the impact of use in this vulnerable population.

Measuring Relative Cardiovascular Health Risks of Inhaled Tobacco Products

Cardiovascular toxicity is a major consequence of both active and passive smoking. The goal of this project is to quantify the relative cardiovascular toxicity of different inhaled tobacco products (e.g., different types of cigarettes, cigarillos, little cigars, e-cigarettes). To achieve this goal, researchers will assess endothelial function in rats by measuring arterial flow-mediated dilation (FMD) using an innovative micro-ultrasound approach; FMD, the process by which arteries dilate in response to increased fluid shear stress (i.e., the stress of blood flow against arterial walls), is a marker of cardiovascular risk that can provide information about the cardiovascular toxicity of different tobacco products. Specific aims are: (1) to assess differences in the acute vascular toxicity of different types of smoked tobacco products (including menthol and non-menthol cigarettes, research cigarettes, cigarillos, and little cigars); (2) to determine the role of specific smoke components (including nicotine, acrolein, acetaldehyde, and cadmium) in acute endothelial toxicity; and (3) to evaluate and understand the acute cardiovascular toxicity of e-cigarette emissions. This research will yield new information about tobacco product toxicity that may be used to inform regulatory activities.

MicroRNAs as Biomarkers for Tobacco Exposure and Heart Disease

Altered expression of microRNAs — short 20-25 nucleotide RNA molecules that negatively regulate gene expression — has been reported in various tobacco-related diseases, such as cardiovascular dysfunction. Tobacco smoke substantially alters the microRNA profile, but the role of microRNAs in the association between tobacco exposure and heart disease has yet to be determined. The specific aim of this study is to explore whether microRNAs can serve as blood-based biomarkers that link heart disease to tobacco use. Researchers will evaluate differences in the plasma microRNA profiles of 40 adult smokers divided into four groups: smokers with or without myocardial infarction and nonsmokers with or without myocardial infarction. Researchers will also profile circulating microRNAs in smokers with or without myocardial infarction who attempt smoking cessation. Next, researchers will profile the circulating microRNAs in mice exposed to acute or chronic tobacco smoke and induced to have acute myocardial infarction in order to examine the effect of tobacco smoke exposure and heart injury on the microRNA profile. Finally, researchers will analyze microRNA alterations in both humans and mice, compare them to the circulating microRNA profiles of various human cardiovascular pathologies, and formulate a microRNA signature that can be used as a biomarker to associate heart disease with tobacco exposure. Research findings will reveal biologically relevant changes associated with tobacco use and exposure in humans and mice and indicate whether microRNAs could be predictive of tobacco-related adverse cardiovascular conditions.

Cancer Center Support Grant: Effects of Very Low Nicotine Content Cigarettes on Intermittent Smokers

Reduced nicotine content cigarettes have the potential to mitigate addiction and the appeal of smoking, thereby reducing cigarette use. Initial studies involving use of very low nicotine content cigarettes (VLNCCs) by daily/heavy smokers have been conducted; although these smokers might potentially escalate smoking in order to avoid nicotine withdrawal symptoms, these studies suggest that increased smoking does not occur in response to lower nicotine content. However, it is not clear whether these findings apply to the large population of non-daily (intermittent) smokers. The goal of this study is to assess the effects of VLNCC use among intermittent smokers. After a two-week baseline period of smoking their own cigarettes, 455 intermittent smokers aged 21 and older will be randomized to smoke one of two types of experimental cigarettes for ten weeks: normal nicotine content cigarettes (NNCCs; 0.8 mg per cigarette) or VLNCCs (0.07 mg per cigarette), matched to the menthol status of subjects’ preferred brand. Specific aims are: (1) to assess cigarette consumption changes between smoking own cigarettes and smoking VLNCCs or NNCCs; and (2) to assess changes in per-cigarette smoking intensity, measured by the two smoking biomarkers cotinine and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), solanesol (a stable marker assayed in cigarette butts), butt weight and length, and smoking topography measures. Investigators will also evaluate individual differences that could moderate response to VLNCCs, including ethnicity (African-Americans vs. white smokers), history of past daily smoking, and starting level of dependence, and will assess changes in smoking behaviors and temporal smoking patterns. Findings from this study may inform the regulation of nicotine levels in cigarettes.

Cigarette Warning Labels: Research Synthesis and Impact on Smoking Behavior

The FDA has a legislative mandate to require new warnings on cigarette packs that communicate the health risks of smoking. In this supplement to an existing research grant, researchers will synthesize the published literature on the impact of warnings on smoking-related outcomes and then will conduct an experiment in which they label smokers’ own cigarette packs with text or graphic warnings to examine real-world impact on smoking behavior.  Specific aims are: (1) to assess the impact of cigarette pack warnings by conducting a systematic review and meta-analysis of the existing literature; and (2) to test the impact of cigarette pack warnings on smoking behavior. To accomplish Aim 1, researchers will search research databases and examine references in review and primary articles, code relevant articles for important study characteristics, and conduct a separate analysis for each key outcome (i.e., cognitive and emotional reactions, risk perception, intention to quit, and the moderating effects of income, race/ethnicity, age, smoking status, sampling method, and study design). To accomplish Aim 2, researchers will randomly assign 2,250 smokers aged 18-65 to one of seven experimental conditions in which smokers’ cigarette packs are labeled with a warning (i.e., three text-only warnings, three graphic warnings, and the current Surgeon General’s warning as a control condition). Researchers will then assess the relationship between warning type (i.e., text or graphic) and cessation behaviors (i.e., quitting, attempting to quit, smoking fewer cigarettes); evaluate the impact of graphic warnings on emotional and cognitive reactions, perceived risk of smoking-related harm, discouragement from smoking, and quit intentions; and examine whether the impact of warnings varies by income level. This research may inform future regulatory activities related to cigarette pack warning labels.

Nornicotine in Smokeless Tobacco as a Precursor for Carcinogen Exposure

N’-nitrosonornicotine (NNN), a tobacco-specific carcinogen, is believed to play an important role in causing esophageal and oral cavity cancer in tobacco users.  NNN is formed from the nitrosation of tobacco alkaloids such as nornicotine. Nornicotine in tobacco products is nitrosated during tobacco processing, but it may also be nitrosated endogenously (i.e., within the body) in the oral cavity, the stomach, or elsewhere.  This is particularly relevant to smokeless tobacco product use, given that keeping smokeless tobacco in the oral cavity for prolonged time periods creates favorable conditions for nitrosation. Information on nornicotine content in individual smokeless tobacco brands does not exist, and the extent of variation among products is unknown. The goal of this study is to generate information on endogenous nitrosation of nornicotine as a function of its content in smokeless products. Specific aims are: (1) to determine the variation of nornicotine content in smokeless products currently marketed in the U.S.; and (2) to investigate the endogenous formation of NNN in smokeless tobacco users. To investigate Aim 1, researchers will analyze a variety of smokeless products (e.g., moist snuff, snus, lozenges, sticks, strips) for nornicotine, nitrate, and nitrite content using liquid chromatography tandem mass spectrometry (LC-MS/MS).  To investigate Aim 2, researchers will randomize 130 smokeless tobacco users aged 18-65 to use a tobacco-free herbal snuff containing various added amounts of stable isotope-labeled nornicotine. Isotope-labeled urinary total NNN will be measured in these subjects by using LC-MS/MS, allowing researchers to differentiate the amount of NNN from endogenous nitrosation of nornicotine versus that from exposure to NNN in tobacco products. The results of this study will provide new information on endogenous NNN formation that may inform regulatory decisions related to nornicotine in tobacco products.

Does Real World Exposure to FDA Graphic Warnings Affect Tobacco Use Behavior?

To date, experimental research on the effectiveness of FDA graphic warning labels on cigarette packages has involved one-time exposure to the labels, an exposure duration that is too brief to generate accurate measurements of changes in tobacco use behavior. The goal of this research is to develop and test an experimental approach that simulates real-world prolonged exposure to graphic warning labels. Researchers will recruit 450 smokers aged 18 and older from three residential addiction treatment programs. After a baseline interview, researchers will affix one of nine experimental graphic warning labels (or a transparent label as a control condition) to patients’ own cigarette packs; after a 30-day exposure period, researchers will conduct follow-up interviews to identify any changes in smoking-related behaviors. Specific aims are: (1) to expose smokers to graphic warning labels repeatedly over time in the course of their usual tobacco use; and (2) to measure the impact of prolonged exposure to graphic warning labels on behavioral (i.e., intent to quit, quit attempts, cigarettes per day, initiation of cessation services) and communication-related (i.e., tobacco risk perception, impacts of cigarette pack warnings, thoughts about abstinence) outcomes. Research findings will provide information about the impact of real-world extended exposure to graphic warning labels on tobacco use-related factors and may inform FDA regulatory activities.

University of Hawaii Cancer Center CCSG: Laboratory Studies of Tobacco Advertising and Labeling Effects on Adolescents

Tobacco marketing practices are known to influence adolescent smoking; however, there is a limited understanding of what characteristics make them effective. The goal of this project is to determine what aspects of marketing and packaging create positive reactions toward cigarettes and may encourage adolescents to smoke. Specific aims are: (1) to investigate the role of colors and male and female models in producing positive reactions to cigarette advertising; (2) to investigate the impact of colors and health labels in producing reactions to cigarettes; (3) to examine gender differences in reactions to advertising and packaging; and (4) to investigate ethnic differences in reactions to advertising and packaging. Researchers will conduct two studies, each with an ethnically diverse group of 200 adolescents aged 12-14. In the first study, researchers will modify existing tobacco advertising materials to emphasize different advertisement elements (e.g., colors, use of models); participants will then be asked about their reactions to the modified and unmodified ads. In the second study, researchers will modify existing cigarette packages in two ways: one in which colors are retained but health warning size is increased, and one in which all color and branding information is removed (i.e., plain packaging); participants will be asked about their reactions to the modified and unmodified packages. The studies will assess participant evaluations of the ads, expectancies about smoking, affective reactions, identification with smokers, willingness to smoke, and (in the second study) the extent to which the package makes smoking seem attractive. Research findings will yield information about how aspects of cigarette advertising and packaging could make smoking appear attractive; these findings may be used to inform regulations to address smoking among adolescents. 

University of Hawaii Cancer Center CCSG: E-cigarette Advertising Exposure, Attitudes, and Use Susceptibility among Cigarette Smokers

Electronic cigarettes (e-cigarettes) may be considered as an alternative to traditional cigarettes, especially among younger smokers. E-cigarettes may be perceived as less dangerous than cigarettes, despite the fact that the health consequences of e-cigarette use are not well understood. The goal of the study is to evaluate whether e-cigarette marketing encourages consumer perceptions that e-cigarettes are less dangerous than cigarettes. Specific aims are: (1) to qualitatively assess young adult cigarette smokers’ perceptions of e-cigarette advertisements and develop explicit and implicit measures of e-cigarette-related attitudes; and (2) to test whether exposure to e-cigarette advertisements is associated with attitudes that e-cigarettes are healthier alternatives to cigarettes and with greater e-cigarette use susceptibility, as well as whether the relationship between e-cigarette advertisement exposure and use susceptibility is mediated by attitude measures. To address Aim 1, researchers will conduct 12 focus groups with 72 young adult daily cigarette smokers (aged 18-35) in order to qualitatively assess perceptions of real e-cigarette advertisements and to develop attitude measures that will be used to pursue the second aim. To address Aim 2, researchers will conduct a laboratory-based study with 400 young adult cigarette smokers who will be exposed to either real e-cigarette advertisements or control images. After exposure, all participants will be assessed on explicit and implicit measures of attitudes toward e-cigarettes as less dangerous alternatives to cigarettes and on measures of susceptibility to future e-cigarette use. Research findings may demonstrate the association between exposure to e-cigarette advertising and attitudes toward e-cigarettes and e-cigarette use susceptibility, and may inform marketing-related regulatory activities.

Dependence Behaviors and Nicotine Pharmacokinetics Associated with blu Electronic Cigarettes in Current Users

Due to their capacity to deliver substantial amounts of nicotine, e-cigarettes may precipitate or perpetuate nicotine dependence. Although systematic assessments of e-cigarette dependence behaviors are limited, it is important to understand how these products affect nicotine dependence and withdrawal behaviors. This study will investigate dependence behaviors and nicotine pharmacokinetics associated with e-cigarette use in experienced users. The investigators will conduct a clinical study measuring use behaviors, nicotine pharmacokinetics, subjective effects, and dependence in 20 experienced adult e-cigarette users (ages 18-55) who are either former smokers or current dual users. Participants will be randomized to use their own brand e-cigarette and two rechargeable e-cigarettes of different nicotine strengths on three study days. Participants will use these products several times each day; use behaviors and nicotine pharmacology will be compared among products and between the first and last use of each day. Plasma nicotine will be measured to assess pharmacokinetics; pharmacodynamics will be measured with heart rate, blood pressure, and oxygen saturation. E-cigarette topography and subjective effects will also be assessed. Findings will reveal if and how experienced users are able to adjust their nicotine exposure with different e-cigarettes and whether these products may be sufficient to maintain dependence. Research findings regarding how e-cigarettes are used and users’ resulting nicotine exposure may inform potential regulatory actions regarding e-cigarettes.

14-Day Nose-Only Inhalation Toxicity Study of NNK in Rats

Human exposure to 4-(methylnitrosamine)-1-(3-pyridyl)-1-butanone (NNK), a tobacco-specific nitrosamine that has been classified as a human lung carcinogen, occurs through smoking tobacco products, using oral smokeless tobacco products, or being exposed to environmental tobacco smoke. The goal of this study is to determine the sub-acute inhalation toxicity of NNK in rats over 14 days of inhalation exposure to NNK aerosols. In this study, six groups of 32 Sprague-Dawley rats (16 males and 16 females per group) will be exposed by nose-only inhalation to one of four dose levels of NNK aerosols or one of two control conditions (vehicle or air) for one hour per day, seven days per week for 14 days. Each study group will contain toxicology (10 rats/sex/group) and exposure assessment (6 rats/sex/group) subgroups. Moreover, three additional groups of toxicology animals (7 rats/sex/group) will be exposed to NNK aerosols by nose-only inhalation for four hours per day, seven days per week for 14 days, and their biological responses will be compared to the one-hour exposure group animals who receive the same exposure doses (i.e., the product of NNK concentration and exposure time will be constant). During the 14-day exposure phase of the study, the rats’ mortality, clinical signs, body weights, food consumption, and pulmonary physiology (breathing rate and minute volume) will be evaluated periodically. One day after the last inhalation dose, researchers will collect tissues from the rats in the toxicology subgroups for histopathological evaluation. Researchers will also evaluate the organ weights, hematology, and blood chemistry of the rats in the toxicology subgroups in order to determine biological responses. Finally, researchers will collect blood and urine from rats in the exposure assessment subgroups at days 1, 8, and 14, and will measure plasma and urine NNK and its metabolites. This project will yield data indicating the risk associated with exposure to NNK.

Chemical Evaluation of Electronic Cigarettes

Electronic cigarettes (e-cigarettes) are gaining popularity in the United States, exacerbating concerns regarding limited research on these products’ safety. In order to understand the chemistry of e-cigarettes, a detailed chemical evaluation of their design and chemical composition, including the aerosol generated with use, is necessary. This study will collect and evaluate the chemical composition of e-cigarette liquids and aerosol. Researchers will test approximately 20 e-cigarette product lines from nine different brands to qualitatively screen for constituents present in the e-liquid and the vapor. Data collected from this study may inform the science base needed to effectively evaluate and regulate e-cigarettes.

13-Week Nose-Only Inhalation Toxicity Study of NNK in Rats

Human exposure to 4-(methylnitrosamine)-1-(3-pyridyl)-1-butanone (NNK), a tobacco-specific nitrosamine that has been classified as a human lung carcinogen, occurs through smoking tobacco products, using oral smokeless tobacco products, or being exposed to environmental tobacco smoke. The goal of this study is to determine the sub-chronic inhalation toxicity of NNK in rats over 90 days of inhalation exposure to NNK aerosols.  In this study, six groups of 46 Sprague-Dawley rats (23 males and 23 females per group) will be exposed by nose-only inhalation to one of four dose levels of NNK aerosols or one of two control conditions (vehicle or air) for one hour per day, seven days per week for 90 days.  Each study group will contain core toxicology, recovery toxicology, and exposure assessment subgroups.  During the 90-day exposure phase of the study, the rats’ mortality, clinical signs, body weights, food consumption, opthalmology, and pulmonary physiology (breathing rate and minute volume) will be evaluated periodically.  One day after the last inhalation dose, researchers will collect tissues from the core toxicology subgroup (10 rats/sex/group) for histopathological evaluation. Researchers will maintain the recovery toxicology subgroup (10 rats/sex/group) for six weeks following the exposure phase, at which time they will analyze tissues in order to evaluate post-exposure recovery. Researchers will also evaluate the organ weights, hematology, blood chemistry, and urinalysis on core and recovery toxicology rats in order to determine biological responses. Finally, researchers will collect blood and urine from exposure assessment (3 rats/sex/group) at weeks 1, 5, 9, and 13, and will measure plasma and urine NNK and its metabolites.  This project will yield data indicating the risk associated with exposure to NNK.

Drug Dependence Clinical Research Program: New Biomarkers for Tobacco Exposure

While data are available on the chemical composition of, and human exposure to, tobacco toxicants in cigarettes, much less is known about new and emerging tobacco products such as snus, electronic cigarettes, and hookah (waterpipe).  The goal of this study is to develop two new biomarkers of exposure: the tobacco alkaloid nicotelline as a biomarker for tobacco smoke particulate matter (TPM, or “tar”), and pseudooxynicotine (PON), the chemical precursor to the tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK). To develop these biomarkers, researchers will analyze urine samples from 120 subjects aged 18-70 using hookah (waterpipe), snus, electronic cigarettes, cigarettes, cigars, or oral snuff. Researchers will also analyze these tobacco products for toxic substances and their precursors. Specific aims are: (1) to explore the utility of nicotelline as a biomarker for the particle phase of tobacco smoke by characterizing levels in smokers’ urine and correlating these levels with existing measures of smoke exposure, including cigarettes per day, amount of tobacco burned, and established biomarkers such as 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and polycyclic aromatic hydrocarbons (PAH); (2) to evaluate PON and its metabolites as biomarkers of exposure to NNK and other tobacco-specific nitrosamines by developing analytical methods for determining urine concentrations of PON and likely metabolites; and (3) to measure concentrations of PON, NNK, other alkaloids, and toxic substances in new and emerging tobacco products in order to determine whether concentrations in the products correlate with urine biomarker concentrations. These new biomarkers will advance the field of tobacco exposure assessment and may inform future regulatory activities.

Taste, Preferences, and Behavior: Effects of Nicotine and Flavorings in Electronic Cigarettes

Electronic cigarette (e-cigarette) usage patterns and health risks are not well understood. The purpose of this project is to determine the effects of e-cigarette nicotine concentration and flavor additives on the preferences, cognitions, affects, and behaviors associated with e-cigarette use, particularly in women of reproductive age. Specific aims are: (1) to determine the effects of altering concentrations of nicotine and various flavors on e-cigarette preference and palatability; and (2) to determine the extent to which different flavor additives determine e-cigarette usage. To meet these aims, investigators will conduct a two-phase study of e-cigarettes with 120 male and female smokers aged 18-45 who report no intention to quit. Phase I will entail a laboratory baseline test of preferences, liking, satisfaction, and effects on craving using high versus low concentrations of nicotine crossed with tobacco-flavored or sweet/masking flavor additives; subjects will identify a preferred e-cigarette flavoring. Phase II will evaluate subjects’ usage patterns of preferred cigarettes and e-cigarettes in their home environments. Subjects will be asked to refrain from smoking cigarettes and will be randomized to one of four e-cigarette conditions (no nicotine–tobacco flavoring; high nicotine–tobacco flavoring; no nicotine–preferred flavoring; high nicotine–preferred flavoring). Subjects will call an interactive voice response (IVR) system each evening for six weeks to answer questions about: daily cigarette and e-cigarette use; nicotine cravings before and after e-cigarette use; e-cigarette liking, affects and cognitions related to use; and situational determinants of e-cigarette use. Subjects will also be asked about regular cigarette use, and cigarette smoking will be tested weekly. Investigators will follow up with subjects at three months to determine if cigarette smoking habits have been altered by the e-cigarette experience. Results will provide information about daily motivations to use cigarettes and e-cigarettes, the influence of flavors and nicotine levels on e-cigarette consumption, and the effects of e-cigarette use on subsequent cigarette smoking. These findings may inform future regulation of alternative tobacco products, particularly if certain flavors or nicotine concentrations are found to be associated with greater use.

GSU TCORS: Testing Tobacco Ad Restrictions and Counterads in a 3D Virtual Retail Store

Exposure to point-of-sale (POS) cigarette advertising and promotions is associated with youth smoking experimentation, progression to regular smoking, unplanned tobacco purchases, and urges to smoke. This project will use a previously-developed virtual convenience store to compare policy options to curb and counter the influence of POS cigarette advertising and pack displays as well as increased visibility of other products such as electronic cigarettes. Studies will be conducted with youth (aged 13-17) current smokers and nonsmokers susceptible to smoking and adult (aged 18 and older) current smokers and recent quitters. Specific aims are: (1) to develop and pilot test virtual store conditions with POS tobacco advertising/product display restrictions, graphic health warnings, and product mix changes using 3D gaming software and eye tracking technology; and (2) to conduct randomized controlled experiments to test the impact of policy options to regulate POS tobacco ads and displays, promotions, graphic health warning signs, and product mix on purchase attempts, urges to smoke, and quit intentions. This study will provide policy-relevant data on the potential impact of restricting and countering tobacco marketing efforts at the POS on youth and adult smoking outcomes.

GSU TCORS: Enhancing the Economic Impact Analysis Used in FDA’s Rules for Tobacco Products

There are numerous challenges inherent in conducting the type of economic impact analysis the U.S. Food and Drug Administration (FDA) uses to inform its regulatory activities. This project will produce new evidence to inform and refine the FDA’s economic impact assessments of future proposed rules related to tobacco use. This will be accomplished through a combination of behavioral economics experiments involving original data collection; acquisition of existing archival, survey, and commercial databases; and merged data analyses that address current and emerging issues. Specific aims are: (1) to assess the impact of FDA regulatory actions and other tobacco control policies (e.g., graphic health warnings, point-of-sale marketing restrictions, flavor bans, pack size restrictions) on tobacco use and related outcomes, including the impact on tobacco use trajectories among young people and adults, the differential impact of these actions on disparate populations, and the differential impact on the use of traditional and emerging tobacco products; (2) to assess the impact of FDA regulatory actions and other tobacco control policies on the consumer surplus (i.e., enjoyment) obtained by tobacco users, via a behavioral economics experiment that will quantify the extent of present bias, projection bias and time inconsistencies in decisions about tobacco use and the implications of these biases for assessing changes in consumer surplus; and (3) to extend the range of costs and benefits involved in assessing the economic impact of FDA regulatory actions to include a broader set of health and economic benefits (e.g. benefits related to reductions in secondhand smoke exposure and maternal smoking during and after pregnancy) than that included in previous FDA assessments. This project may produce new evidence to inform the FDA’s economic impact assessments of future proposed rules concerning tobacco products.

GSU TCORS: Conducting Consumer Behavior, Risk Perception and Media Research on Novel Tobacco Products

Tobacco companies are rapidly transitioning from combusted products to novel nicotine delivery systems (e.g., e-cigarettes) and alternative tobacco products (e.g., little cigars); however, the actual risk of these products is uncertain, as is whether these products will be used in conjunction with other tobacco products or possibly deter quitting behavior. Investigators will assess use and perceptions of new and emerging tobacco products in a nationally representative sample of adults aged 18 and older. Specific aims are: (1) to assess the patterns of use and perceptions of risk of novel tobacco products and alternative products using quantitative (i.e., annual surveys conducted in years 1 through 5) and qualitative (i.e., six focus groups conducted in years 1, 3 and 5) research methodologies; and (2) to develop and test traditional and new media messages (based on the findings of Aim 1) to improve the quality and accuracy of consumer perceptions of risk, particularly for novel and alternative products. This project will provide new information about risk perceptions, attitudes, and normative beliefs about an array of tobacco products that may inform FDA communications and regulations related to these products.

Pennsylvania State University Tobacco Center of Regulatory Science (TCORS)

This Center will evaluate the effects of switching smokers from their usual cigarettes to reduced nicotine content cigarettes on nicotine dependence and tobacco harm, with a special focus on vulnerable (e.g. low socioeconomic status [SES], mental disorders) populations. Project 1, a randomized controlled trial, will evaluate the effect of progressive nicotine reduction in cigarettes on smoking behaviors, smoking biomarkers, and stress in smokers with low SES. Project 2, a second randomized controlled trial, will evaluate the effect of progressive nicotine reduction in cigarettes on smoking behavior, toxin exposure, and psychiatric symptoms in smokers with comorbid mood and/or anxiety disorders. Project 3 will evaluate free radical exposure and oxidative stress associated with use of conventional and reduced nicotine cigarettes, via analysis of machine smoking data and a product switch intervention study.

PSU TCORS: Switching to Progressively Reduced Nicotine Content Cigarettes in Smokers with Lower Socioeconomic Status

A potential strategy to reduce harm from tobacco is reducing nicotine content and delivery to non-addictive levels. The effectiveness of this strategy needs to be demonstrated in different populations whose response to reduced nicotine content (RNC) cigarettes might be substantially mediated by personal or environmental factors. To address the question of whether progressively lowering nicotine content in cigarettes can reduce or eliminate nicotine dependence in low socioeconomic status (SES) populations, investigators will test the following specific aims: (1) to determine the effect of progressive nicotine content reduction on biological levels of nicotine, its metabolites, and other biomarkers of smoking exposure; (2) to determine the predictors of participant drop-out/relapse; and (3) to determine if a gradual reduction in nicotine content versus same nicotine content is associated with a reduction in stress. This randomized double-blinded controlled trial will evaluate nicotine intake in 400 adult smokers with lower socioeconomic status who switch to progressively reduced nicotine content test cigarettes. Investigators will randomize smokers to either an RNC group with a gradual step-wise reduction in nicotine from 11 mg to 0.3 mg per cigarette in five stages, or a control group with nicotine content that approximates that of their usual cigarette brand. Test nicotine research cigarettes will be obtained through the National Institute on Drug Abuse (NIDA) Drug Supply Program (part of the National Institutes of Health). The RNC group will include menthol and non-menthol flavors. Additional measures will include changes in psychological scales and biomarkers of stress. This study will provide empirical data that could inform regulatory actions related to reducing cigarette nicotine content.

PSU TCORS: Reduced Nicotine Cigarettes in Smokers with Mood and Anxiety Disorders

A potential strategy to reduce harm from tobacco is reducing nicotine content and delivery to non-addictive levels. The effectiveness of this strategy needs to be demonstrated in different populations whose response to reduced nicotine content (RNC) cigarettes might be substantially mediated by personal or environmental factors. This randomized controlled trial will evaluate the effect of progressive cigarette nicotine reduction on smoking behavior, toxin exposure, and psychiatric symptoms in smokers with comorbid mood and/or anxiety disorders. Specific aims include: (1) to assess the effect of switching to gradually reduced nicotine content cigarettes on product use patterns and biomarkers of exposure in smokers with mood and/or anxiety disorders; (2) to assess the effect of switching to gradually reduced nicotine content cigarettes on psychiatric and nicotine withdrawal symptoms in smokers with unipolar mood and/or anxiety disorders; and (3) to assess the effect of switching to gradually reduced nicotine content cigarettes on self-perception of tobacco dependence, self-report of intention to quit smoking, and actual smoking cessation attempts. Investigators will randomly assign 200 adult smokers with a unipolar mood and/or anxiety disorder to smoke research cigarettes containing either usual nicotine content (similar to their usual brand) or reduced nicotine content (progressively reduced from approximately 11 mg to 0.3 mg over five steps). This study is designed to test the hypotheses that nicotine intake, as measured by plasma cotinine concentrations, will decline as a function of cigarette nicotine content, and that reducing the nicotine content of the cigarettes on a gradual basis will minimize potential compensatory increases in tobacco exposure biomarkers and psychiatric symptoms compared to the usual brand group. This study will provide empirical data that could inform regulatory actions related to reducing cigarette nicotine content.

PSU TCORS: Free Radical Exposure and Oxidative Stress from Conventional and Reduced Nicotine Cigarettes

Oxidative stress from tobacco smoke exposure has a widespread impact on many critical cellular pathways, including cell proliferation, survival and inflammation. A major source of smoking-related oxidative stress is from exposure to free radicals such as reactive oxygen and nitrogen species, which play fundamental roles in the development of many diseases including cancer and heart disease. An assessment of free radical exposure and oxidative stress is critical to help gauge the relative harm of current and new tobacco products. This project will evaluate free radical exposure and oxidative stress associated with the use of conventional and reduced nicotine cigarettes, via a series of laboratory-based machine smoking studies and product switch intervention studies in healthy adult smokers (aged 21 or older). Specific aims include: (1) to determine the free radical content of mainstream tobacco smoke from popular U.S. menthol and non-menthol cigarettes as well as newer and developing low and ultra-low nicotine products; (2) to determine if smoking behavior in 80 smokers is impacted by switching to lower nicotine or lower free radical products, and if behavior changes lead to altered exposure to tobacco smoke free radicals; and (3) to determine if 108 smokers who switch from their usual high nicotine/free radical products to low nicotine or low free radical products exhibit increased or decreased levels of oxidative stress and damage. Together, these studies will result in a comparative assessment of exposure to toxic and harmful free radicals for smokers of different tobacco products. This project constitutes the first formal assessment of exposure of smokers of different tobacco products to toxic and harmful free radicals and has the potential to inform regulatory decisions intended to limit user exposure to these toxic agents.

Yale Tobacco Center of Regulatory Science

The Center will conduct research to evaluate how flavors (including menthol), sweeteners, and related factors affect the initiation of, preference for, and development of addiction to current tobacco and potential modified risk tobacco products. Populations studied will include adolescent and adult mice and rats, adolescent and young adult smokers and nonsmokers, and chronic smokers. Project 1 will study the effects of flavors on nicotine choice and dopaminergic/central reward mechanisms in mice and rat models. Project 2 will study menthol’s effects on nicotine reinforcement in smokers. Project 3 will evaluate whether commonly used flavor constituents, including menthol, alter reinforcement from e-cigarettes in adolescent smokers. Project 4 will examine factors (including product attributes and informal/formal sources of information about risks) that influence both the perceptions of risk and interest in using tobacco products in different populations (i.e. populations that vary by age, race, smoking status, and socioeconomic status).

Project 3: Conducting Consumer Behavior, Risk Perception and Media Research on Novel

Tobacco companies are rapidly transitioning from combusted products to novel nicotine delivery systems (e.g., e-cigarettes) and alternative tobacco products (e.g., little cigars); however, the actual risk of these products is uncertain, as is whether these products will be used in conjunction with other tobacco products or possibly deter quitting behavior. Investigators will assess use and perceptions of new and emerging tobacco products in a nationally representative sample of adults aged 18 and older. Specific aims are: (1) to assess the patterns of use and perceptions of risk of novel tobacco products and alternative products using quantitative (i.e., annual surveys conducted in years 1 through 5) and qualitative (i.e., six focus groups conducted in years 1, 3 and 5) research methodologies; and (2) to develop and test traditional and new media messages (based on the findings of Aim 1) to improve the quality and accuracy of consumer perceptions of risk, particularly for novel and alternative products. This project will provide new information about risk perceptions, attitudes, and normative beliefs about an array of tobacco products to inform FDA communications and regulations related to these products.

The Science of Decision-Making: Connecting People and Policy (GSU TCORS)

This Center will investigate the human and economic factors that contribute to decision-making regarding the use of tobacco products. Specifically, the Center‘s projects will examine the economic, point of sale, consumer behavior, risk perception, and communication factors that influence tobacco use behaviors, particularly for novel and alternative tobacco products, and will provide evidence that has direct implications for FDA regulatory actions. Project 1 will involve human economic behavioral experiments that produce new evidence to inform the FDA’s economic impact assessments of future proposed rules. Project 2 will study consumer reactions to tobacco marketing using visual immersion methodology in order to examine the point of sale environment and how it can be changed to influence consumer behavior. Project 3, which focuses on individual perception of risk of tobacco product use, will conduct qualitative research to monitor the use and perceptions of tobacco products, with a special emphasis on alternative and novel products.

Vermont Center on Tobacco Regulatory Science

The Center will focus on researching tobacco product use and effects in vulnerable populations, including women of childbearing age/pregnant women, individuals with comorbid substance use disorders, and individuals with comorbid serious mental illness. In this context, the Center will study the following: (1) reducing the addiction potential of cigarettes and other tobacco products by reducing their nicotine content, and (2) the impact of new products on biomarkers of exposure and health outcomes in vulnerable populations. The Center will complete three multi-site research projects evaluating the effects of very low nicotine content (VLNC) cigarettes in vulnerable populations. Project 1 will examine response to VLNC cigarettes among women of childbearing age including pregnant women, investigating (a) behavioral-economic tests of reinforcing effects/abuse liability, (b) compensatory smoking, (c) ability to substitute for higher-nicotine content cigarettes, (d) effects on motivation to quit, (e) neurobiological response (e.g., neuroimaging with non-pregnant women only), and (f) biomarkers of tobacco-smoke/carcinogen exposure, pulmonary and cardiovascular effects, and birth outcomes. Project 2 will investigate response to VLNC cigarettes in smokers with substance use disorders. Project 3 will focus on testing VLNC cigarettes in smokers with major depression.

UVM TCORS: Low Nicotine Content Cigarettes in Vulnerable Populations: Opioid Abusers

Reducing the nicotine content of cigarettes has shown promising beneficial effects (e.g., decreased smoking rate, reduced toxicant exposure, and increased cessation) in the general population, but studies have excluded vulnerable populations such as individuals with comorbid drug dependence, who may respond with compensatory increases in smoking rate or inhalation patterns, potentially increasing exposure and adverse health effects. Investigators will conduct two studies to evaluate the abuse liability and health effects of reduced nicotine content (RNC) cigarettes in 60 opioid-dependent smokers (aged 18-70) by comparing cigarettes varying in nicotine content across a range of doses starting from levels approximating those in normal nicotine content (NNC) cigarettes to low nicotine levels using brief- and extended-exposure protocols. Study 1 will evaluate the effects of brief exposure to RNC cigarettes among opioid-maintained smokers in the clinical laboratory under double-blind conditions, using a within-subjects design to examine the effects of RNC nicotine cigarettes on subjective measures (e.g., satisfaction, craving relief) and the extent to which the RNC cigarettes substitute for NNC cigarettes (0.80 mg) under conditions of varying constraints on the latter. Study 2 will evaluate the effects of extended exposure to RNC cigarettes in 400 opioid-maintained smokers using a between-subjects design that randomly assigns participants to one of four cigarette conditions (0.80, 0.26, 0.12 or 0.03 mg nicotine) for a 12-week period. Specific aims are: (1) to evaluate whether RNC cigarettes substitute for NNC cigarettes during brief exposure without producing compensatory increases in smoking, assessed by expired-breath carbon monoxide (CO); (2) to compare extended exposure to RNC and NNC cigarettes with regard to daily smoking rates (i.e., self-report, cotinine), tobacco smoke exposure levels (e.g., breath CO, urine cotinine), and nicotine dependence severity; (3) to assess adherence to assigned tobacco products and use of other nicotine products during the extended exposure conditions; (4) to quantify the effects of RNC cigarettes on biomarkers of exposure to tobacco carcinogens (e.g., cotinine, nitrosamine-4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL], polycyclic aromatic hydrocarbons [PAH]), markers of pulmonary and cardiovascular risk, and use of other non-prescribed drugs during extended exposure; and (5) to compare RNC and NNC cigarettes on abstinence-induced craving, withdrawal, cigarette demand and neurocognitive function. Data from this study may inform FDA policy decisions regarding reduced-nicotine tobacco products.

UVM TCORS: Low Nicotine Content Cigarettes in Vulnerable Populations: Childbearing Age Women

Reducing the nicotine content of cigarettes has shown promising beneficial effects (e.g., decreased smoking rate, reduced toxicant exposure, and increased cessation) in the general population, but studies have excluded vulnerable populations such as low-income pregnant women, who may respond differently due to greater vulnerability to smoking and nicotine dependence. This project involves two studies that will evaluate how pregnant and non-pregnant smokers aged 18-44 might respond to reduced nicotine content (RNC) cigarettes. In Study 1, investigators will assess the effects of brief exposure to cigarettes of varying nicotine yield (0.80, 0.26, 0.12, 0.03 mg in 60 non-pregnant women; usual brand, 0.10, 0.03 mg in 60 pregnant women) on craving, nicotine withdrawal, and the degree to which the RNC cigarettes substitute for typical nicotine content cigarettes in behavioral-economic tests of smoking preference. In Study 2, 400 non-pregnant and 200 pregnant smokers will be randomized to smoke one of the above doses during an extended exposure phase (12 weeks in non-pregnant women; through delivery in pregnant women). Specific aims are: (1) to compare the subjective and behavioral effects of cigarettes varying in nicotine content in non-pregnant and pregnant women; (2) to compare extended exposure to these cigarettes on measures of smoking rate (cigarettes per day, urine cotinine levels) and nicotine dependence severity in non-pregnant and pregnant women; (3) to assess adherence to assigned tobacco products during the extended exposure study; (4) to quantify the effects of extended exposure to RNC cigarettes on biomarkers of exposure (e.g., total cotinine, nitrosamine-4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL], polycyclic aromatic hydrocarbons [PAH]), markers of thrombotic risk and lung function, and sonographic estimates of fetal growth and birth outcomes; and (5) to compare the effects of these cigarettes on abstinence-induced craving, withdrawal, cigarette demand, and neurocognitive function in non-pregnant and pregnant women. This project will provide new information about how this highly vulnerable subgroup of smokers might respond to a nicotine reduction policy.

UVM TCORS: Low Nicotine Content Cigarettes in Vulnerable Populations: Currently Depressed

Reducing the nicotine content of cigarettes has shown promising beneficial effects (e.g., decreased smoking rate, reduced toxicant exposure, and increased cessation) in the general population. Studies to date have excluded vulnerable populations such as individuals with comorbid psychiatric illness, who may respond to reductions in the nicotine content of cigarettes with increases in psychiatric symptoms and/or with compensatory smoking. This project involves two studies that will evaluate relationships between the nicotine content of cigarettes and outcomes in smokers (aged 18-70) with major depressive disorder (MDD). Study 1, conducted in 60 subjects, will use a within-subjects design to compare effects of cigarettes varying in nicotine content on reinforcing efficacy, compensatory smoking, amelioration of abstinence-induced craving and withdrawal, and smoker preference for normal nicotine content (NNC) vs. reduced nicotine content (RNC) cigarettes under different cost conditions. Study 2, a randomized clinical trial including 400 subjects, will examine the effects of 12-week exposure to these cigarettes on smoking rate, nicotine dependence, depression severity, neurocognitive function, acceptability, and biomarkers of toxicant exposure and other health outcomes. Specific aims are: (1) to compare the subjective and behavioral effects of cigarettes varying in nicotine content (0.80, 0.26, 0.12, 0.03 mg) in smokers with MDD; (2) to compare these cigarettes with regard to measures of use (e.g., cigarettes per day, total cotinine) and nicotine dependence severity in smokers with MDD over a 12-week exposure period; (3) to assess adherence to assigned tobacco products during the extended exposure study; (4) to quantify the effects of extended exposure on biomarkers of exposure to tobacco carcinogens (e.g., nitrosamine-4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL], polycyclic aromatic hydrocarbons [PAH] metabolites), markers of pulmonary and cardiovascular risk, depression symptoms, cognitive dysfunction and smoking topography; and (5) to compare the effects of these cigarettes on abstinence-induced craving, withdrawal, cigarette demand, and neurocognitive function in smokers with MDD. This study will provide new information about the effects a nicotine reduction policy may have on smokers with MDD.

VCU Center for the Study of Tobacco Products

The Center will create an integrated, iterative modified risk tobacco product evaluation model that incorporates analytic laboratory methods, toxicant exposure, abuse liability testing using human laboratory methods, longer-term effects using randomized control trial methods, and studies of attitudes, beliefs, and perceived effects using quantitative and qualitative methods to inform tobacco product regulation across all product types (combustible, oral, or vapor). The first product category to be studied will be e-cigarettes. Project 1 will examine factors (e.g., design features, topography, unorthodox use behaviors) that influence e-cigarette nicotine and toxicant yield. Project 2 will determine the use behaviors, effects, and toxicant exposure associated with e-cigarette use and abuse liability. Project 3 will characterize the effects of real-world e-cigarette use in the natural environment via a randomized controlled trial. Project 4 will study user attitudes, beliefs, and perceived effects of e-cigarettes using qualitative and quantitative methods, and examine unorthodox e-cigarette use behaviors.

VCU TCORS: Analytical Lab Methods for MRTP Evaluation

Understanding yields of toxicants in combustible tobacco products generally requires chemical analysis of product emissions. Emissions analysis historically relied on smoking machines; however, few models have been developed for evaluating the health risks associated with novel tobacco products such as e-cigarettes. This project will examine factors (e.g., design features, topography, and unorthodox use behaviors) that influence e-cigarette nicotine and toxicant yield utilizing a “playback” puffing machine method that mimics human puffing behavior. Specific aims are: (1) to develop a heat and mass transfer model to predict e-cigarette nicotine yields as a function of product design and puff parameters; (2) to use a validated playback puffing machine to generate e-cigarette emissions using puffing behavior recorded from e-cigarette users (collected as part of Project 2, below); and (3) to study how unorthodox use behaviors and product manipulation influence nicotine and other toxicant yields of e-cigarettes and other novel products. This project has the potential to inform the regulation of novel tobacco products by developing a model for measuring toxicant yields under real-life use conditions.

VCU TCORS: Randomized Control Trial Methods for MRTP Evaluation

Data addressing how long-term e-cigarette use influences toxicant exposure, user health, and concurrent cigarette smoking are very limited. This project will characterize the effects of real-world e-cigarette use in the natural environment via a multi-site randomized controlled trial. Specific aims are: (1) to characterize product influence on toxicants, biomarkers, health indicators, and disease risk; (2) to determine the tobacco abstinence symptom and adverse event profile associated with real-world product use; and (3) to examine the influence of novel product use on conventional tobacco product use. Investigators will randomly assign 520 e-cigarette-naïve cigarette smokers (aged 18-59) who are interested in reducing their tobacco use to one of four conditions for six months: high-nicotine dose e-cigarette, mid-nicotine dose e-cigarette, zero nicotine dose (placebo) e-cigarette, or a control condition that includes use of a non-combustion, non-nicotine, non-vapor, imitation cigarette substitute. Investigators will measure exposure to the carcinogenic nitrosamine NNK (via its metabolite NNAL in urine); carbon monoxide (via exhaled air); nicotine (via its metabolite cotinine in urine); heart rate; blood pressure; biochemical and hematologic health indices (e.g., lipoproteins, hemoglobin, hematocrit); pulmonary function (via spirometry); biomarkers of oxidative stress (e.g., 8-lsoprostane, glutathione, 8-OHDG); abstinence symptoms; and adverse effects (e.g., dry mouth, throat, and eyes; heart pounding; nausea). This project will develop a randomized controlled trial model that can be used to evaluate any novel tobacco product, not just e-cigarettes.

VCU TCORS: Human Lab Methods for MRTP Evaluation

E-cigarette safety and use behaviors require further study. This project will determine the behavioral effects and toxicant exposure associated with e-cigarette use and their abuse liability. Specific aims are: (1) to demonstrate how human laboratory methods can reveal product use behaviors, toxicant exposure, and effects, (2) to demonstrate how human laboratory methods can determine product abuse liability; and (3) to determine how unorthodox use behavior influences e-cigarette effects. Six studies in subjects aged 18-55 will be conducted as part of this project: a two-condition (topography measurement with mouthpiece vs. no mouthpiece) within-subject study involving experienced e-cigarette users; a study in which a nicotine-delivering e-cigarette is used to examine the effects of varying nicotine concentrations in experienced e-cigarette users and e-cigarette-naïve cigarette smokers; a five-day study conducted in e-cigarette-naïve cigarette smokers that compares the toxicant exposures and other effects of an e-cigarette, an inhaler, conventional tobacco cigarettes, and tobacco abstinence; two separate within-subject short-term laboratory studies evaluating the reinforcing efficacy of a low-dose e-cigarette, a high-dose e-cigarette, and a nicotine inhaler, conducted with experienced e-cigarette users and e-cigarette-naive cigarette smokers; and a within-subject study with two conditions (unorthodox e-cigarette use vs. conventional use) conducted in subjects experienced with both methods to test whether unorthodox use (i.e., “dripping” nicotine liquid onto the e-cigarette heater) alters user nicotine exposure and effects. This project will demonstrate how human laboratory methods can inform tobacco product evaluation by determining the behavior, effects, and toxicant exposure associated with product use and how these methods can inform abuse liability assessment.

VSU TCORS: Quantitative and Qualitative Methods for MRTP Evaluation

New evaluation methods are needed to help explain patterns of modified risk tobacco product (MRTP) consumption and prevalence. This project will demonstrate how a mixed methods approach can be used to generate empirically-based, descriptive models of MRTP-related attitudes, beliefs, motivations and perceived effects (including adverse events) associated with product use and intentional misuse. Specific aims are: (1) to characterize and describe the attitudes and beliefs, motivations, and perceived effects associated with e-cigarette use behaviors; and (2) to examine methods of unorthodox e-cigarette use behaviors. Concept mapping, an integrated mixed method participatory research approach, will be used to describe user attitudes and beliefs regarding e-cigarettes, motivations for e-cigarette use; and perceived beneficial and adverse effects of e-cigarette use. The study will include 500 e-cigarette users (aged 18 and older) who will complete online activities that involve brainstorming statements in response to a prompt about e-cigarette use, sorting these statements into conceptually similar categories, and then rating the importance of each statement. Investigators will also conduct a content analysis of YouTube videos and Internet forums that depict unorthodox e-cigarette use behaviors, such as mixing high-dose nicotine liquids and/or dripping liquid directly on the e-cigarette heater. This project will demonstrate how a mixed methods approach can be used to generate empirically-based, descriptive models of MRTP-related attitudes, beliefs, motivations and perceived effects that can be used to inform the development of comprehensive MRTP regulation.

Yale TCORS: Effects of Flavors on Nicotine Choice and Central Reward Mechanisms

In addition to nicotine, dissolvable tobacco products contain high amounts of sweeteners, flavors, menthol and other cooling agents. Nicotine, sweeteners, flavors and menthol in tobacco products have a complex effect on peripheral sensory systems (mouth, nose and throat) as well as on central reward circuits in the mesolimbic dopamine system, thereby signaling brain reward pathways that influence use behaviors and addiction. This project will study the effects of flavors on nicotine choice and dopaminergic/central reward mechanisms in mice and rat models. Specific aims are: (1) to determine whether flavor constituents in dissolvable tobacco products alter oral nicotine intake; and (2) to examine whether flavor constituents of dissolvable tobacco products increase nicotine reinforcement and nicotine-taking by enhancing phasic dopamine release. Together, these aims will test the hypotheses that flavorings such as sweeteners and menthol affect initiation and the addictive properties of dissolvable tobacco products.

Yale TCORS: Menthol’s Effects on the Nicotine Reinforcement in Smokers

Menthol is an additive in the majority of cigarettes, although at widely different concentrations. Research suggests that menthol may facilitate addiction dependence and maintenance when combined with nicotine. However, the potential reinforcing properties of menthol have not been examined with systematic studies in controlled settings, and human studies examining the reinforcing effects of menthol in combination with nicotine are lacking. This study is designed to test one overarching specific aim: to determine if menthol administered by inhalation via e-cigarettes or orally via sublingual tablet changes the reinforcing effects of pure nicotine administered intravenously in cigarette smokers who smoke mentholated or non-mentholated cigarettes. Exploratory aims include: (1) to determine if menthol’s reinforcing effects are dose dependent; and (2) to determine if inhaled or sublingual menthol changes the cardiovascular, cognitive, and withdrawal suppressing effects of intravenous nicotine; and to determine if sublingual or inhaled menthol will be reinforcing by itself. In two double-blind, placebo-controlled studies (one using e-cigarettes and one using a menthol sublingual tablet), investigators will enroll 160 young adult smokers (aged 18-30) stratified for menthol preference; nicotine will be delivered intravenously, and menthol will be delivered via inhalation and sublingual routes.  For both studies, the main outcome measure will be subjective drug effects, which will be measured using the Drug Effects Questionnaire (DEQ). Determining the reinforcing effects of menthol in combination with nicotine in this study will contribute to the knowledge needed to inform science-based policies regarding additives in tobacco products.

Yale TCORS: Flavors and E-cigarette Effects in Adolescent Smokers

Adolescents are highly susceptible to using novel tobacco products like e-cigarettes. This project will evaluate whether commonly-used flavor constituents, including menthol, alter reinforcement from e-cigarettes in adolescent smokers. The project will include two studies conducted with 140 adolescent smokers aged 15-18. The first study will examine the following: whether menthol at doses that produce low and high cooling sensations alters reinforcement experienced from e-cigarettes that contain low (6 mg/ml) or high (12 mg/ml) levels of nicotine; whether these menthol doses are by themselves reinforcing; and whether preference for menthol vs. non-menthol e-cigarettes in the laboratory is related to the tobacco product type (i.e. menthol/non-menthol) used at one- and two-year follow-up. The second study will determine if a flavor (e.g. cherry, chocolate), when compared to menthol or in combination with menthol, alters the reinforcement from e-cigarettes containing nicotine. Specific aims are: (1) to examine if inhaled menthol doses that produce low and high cooling effects alter reinforcement from e-cigarettes containing low and high nicotine doses; (2) to explore if response to e-cigarettes containing menthol in the laboratory predicts preference for mentholated tobacco products at one- and two-year follow-up; and (3) to examine the independent and combined effects of inhaled doses of menthol and a second flavor on reinforcement from e-cigarettes containing nicotine. Investigators will also explore how smoking e-cigarettes relates to smoking regular cigarettes. This study will elucidate the responses of adolescent smokers to e-cigarettes and determine if flavors alter their addictive potential.

Yale TCORS: Economics, Experiments and PATH Data: Creating Knowledge for Tobacco Regulation

A wide array of tobacco product-related factors, including product attributes and informal/formal sources of information about risks, influence risk perceptions and interest in use. Investigators will conduct school-based and online experiments that will provide information about emerging combinations of product attributes in advance of widespread use. Experiments will be conducted in 4000 subjects, including youth (aged 13-17) in largely minority high schools, young adults (aged 18-25), and adult current smokers (aged 18 and older). Specific aims are: (1) to understand how individuals who vary by age, race, smoking status and socioeconomic status perceive and trade-off the potential risks, attributes, and design features of cigarettes, including low levels of nicotine, low levels of toxins, menthol, and sweet flavoring; (2) to examine perceptions of e-cigarette risk and attributes, specifically flavorings (menthol and sweet), levels of nicotine, and non-combustibility (i.e., ability to use despite smoking bans); (3) to study how source and media types (including graphic warning labels) affect the credibility of information about menthol added to cigarettes and e-cigarettes; (4) to analyze peer effects on e-cigarette use; and (5) to use secondary data from the Population Assessment of Tobacco and Health Study (PATH) and the Current Population Survey-Tobacco Use Supplement (CPS-TUS) (both of which include data on conventional cigarette smoking as well as emerging tobacco products) in combination with experiment results to predict the impact of potential regulations on tobacco use nationally and by subgroup. This project will yield data concerning risk perceptions and use intentions among youth and other vulnerable populations that may inform regulatory decisions related to product attributes and communication campaigns that convey the risks of product use.

A Mixed Methods EMA Assessment of Cognition and Behavior among New ENDS Users

Electronic nicotine delivery systems (ENDS), also known as e-cigarettes, are the most prevalent of the emerging noncombustible products. Research suggests that African-American smokers are less likely than White smokers to try or use ENDS, perhaps due to a greater degree of perceived harm associated with ENDS, a preference for menthol, or cultural norms. However, differential adoption of ENDS by race may not continue as mentholated ENDS are increasingly marketed to African-Americans. The goal of this study is to evaluate how all smokers, including African-American and menthol smokers, experience and initiate ENDS use. Specific aims are: (1) to examine how the immediate environmental and psychological contexts of cigarette and ENDS use vary within subjects; (2) to examine how these contexts vary between subjects by menthol preference and race; and (3) to examine participants’ “lived experience” of the meaning, influences, and utility of cigarette and ENDS use. To meet these aims, investigators will conduct an observational study involving three weeks of ecological momentary assessment (EMA) and in-depth interview data collection, followed by 30-day follow-up telephone contact to assess cigarette and ENDS use. Subjects will include 100 daily cigarette smokers aged 18 and older, stratified into four groups by menthol use and race (non-Hispanic White and non-Hispanic Black). In Week 1, participants will collect baseline data on their usual smoking pattern. In Week 2, participants will receive a week’s supply of ENDS and instructions to use the products at least three times daily. In Week 3, investigators will replenish participants’ ENDS supply and encourage participants to use the products as they see fit. Over the three weeks, participants will use a previously-developed EMA data collection system to provide real-time data (at four random times per day) on immediate environmental context (location, smoking restrictions and presence of others), current psychological states (self-efficacy, outcome expectancies about ENDS and cigarette use, mood), and tobacco use-related items (craving, satisfaction, cigarette or ENDS use, and duration/amount of product used). Participants will also take part in a semi-structured in-depth interview at the end of each week; Week 1 interviews will focus on a process evaluation of the EMA data collection experience, while Week 2 and 3 interviews will focus on how ENDS-associated cognitions, expectancies and norms evolve with ENDS use and increasing familiarity with the product. Findings will provide information about the immediate environmental contexts and psychological correlates associated with ENDS initiation in menthol and non-menthol smokers interested in trying ENDS.

A Regulatory Framework for Substantial Equivalence Product Applications under the FSPTCA

The Family Smoking Prevention and Tobacco Control Act of 2009 grants FDA the authority to conduct a pre-market review of new, revised and modified tobacco products. Under the law, tobacco product sponsors may file an application for exemption from pre-market review if they believe that a new product is “substantially equivalent” (SE) to an existing product. The FDA may grant an SE marketing order if it determines that the new product either has the same characteristics (i.e., materials, ingredients, design, composition, heating source, or other features) as a product on the market as of February 15, 2007, or has different characteristics but does not raise different questions of public health. The goal of this project is to establish a foundation for SE regulatory science by harnessing the science of product equivalence from other realms, understanding the economics and incentives facing tobacco product sponsors when submitting an SE application versus other types of applications, generating a body of research that can inform rigorous evaluation of product applications, and generating a body of research to inform and advance the study of tobacco product equivalence and potential health outcomes. Investigators will demonstrate potential effects on the cigarette market of a relatively low threshold for SE and develop a theoretical model of population outcomes depending on the stringency of research requirements for SE applications. Specific aims are: (1) to analyze the statutory, legislative, and regulatory history and the scientific methods for determining equivalence in FDA-regulated product arenas other than tobacco products as well as internal tobacco industry research on product modification and SE; (2) to conduct a preliminary investigation of the tobacco market and population effects of industry response to the ban on “light” descriptors under a permissive versus restrictive SE approach; and (3) to develop and empirically test a mathematical model of SE review, possible tobacco market incentives, and population health outcomes. This research will provide both a theoretical framework and an empirical basis for FDA’s SE pre-market review criteria.

Assessment of Tobacco Constituent Pharmacology and Behavior in Nonclinical Models: Determination of Behaviorally Effective Tobacco Constituent Doses in Rodents

Although nicotine is the primary addictive constituent in tobacco, studies indicate that tobacco contains additional non-nicotine constituents that may have addictive potential. These constituents include, but are not limited to, anatabine, cotinine, and myosmine. Because no previous studies have evaluated these compounds in nonclinical models, the goal of this project is to define behaviorally active doses of anatabine, cotinine, and myosmine. Investigators will test five doses of continine, anatabine, and myosmine in adult rodents using a locomotor activity protocol to establish dose response curves for each constituent. Study aims are: (1) to characterize dose response curves for the non-nicotine tobacco constituents anatabine, cotinine, and myosmine; and (2) to use these dose response curves to determine relevant constituent doses for subsequent studies of abuse liability in rodents. Once behaviorally active doses have been established, these doses can be used in future behavioral pharmacology studies; furthermore, information on non-nicotinic tobacco constituents may help inform FDA product review and regulation.

Modeling the Policy Impact of Cigarette and Smokeless Use on U.S. Mortality

Smokeless products have been proposed as less harmful alternatives to cigarette smoking. However, among groups with the highest cigarette smoking rates (i.e., males and young adults), smokeless use may be added to, rather than substituted for, cigarette smoking, thereby increasing overall toxicant exposure and/or delaying cessation. The goal of this project is to conduct statistical analyses of the transitions to and from cigarette and smokeless tobacco use in light of policy effects on initiation, cessation, multiple product use, and quantity smoked. Investigators will apply statistical analyses to three existing models, a tobacco control policy model (SimSmoke) and two natural history of disease models (the Michigan-Fred Hutchinson model and the Massachusetts General Hospital Lung Cancer Policy Model [LCPM]). These models were developed as part of the National Cancer Institute’s Cancer Intervention and Surveillance Modeling Network (CISNET). Specific aims are: (1) to conduct a descriptive analysis of cigarette and smokeless tobacco use patterns, quit rates and addiction measures by age and gender, using the Tobacco Use Supplement (TUS); (2) to collect state- and federal-level policy data and review the literature on policy effects on cigarette and smokeless use; (3) to conduct multivariable analyses to distinguish use, initiation, cessation and dose patterns of sole and dual use and to determine how policies are associated with these patterns for cigarette and smokeless users; (4) to extend the SimSmoke, Michigan and LCPM models to examine trends in cigarette and smokeless use, and to develop SimSmoke models for two states with different policy structures (Minnesota and Kentucky) to gauge how the effects of FDA regulations may vary depending on state policies; (5) to adapt the models to estimate the incidence of tobacco-related disease (e.g., lung, head and neck and pancreatic cancers; chronic obstructive pulmonary disease, all cause-mortality) resulting from sole and dual use of cigarettes and smokeless tobacco; and (6) to adapt the models to compare the impact of FDA regulations (e.g. health warnings, retail point-of-sale restrictions, regulation of product content) on national cigarette and smokeless tobacco use prevalence (in total and by age and gender), use patterns, and tobacco-attributable deaths. The models will be developed with the capacity and flexibility to incorporate new data (e.g., Population Assessment of Tobacco and Health [PATH] study data) as it becomes available. This research will provide new information about the effects of possible FDA marketing and product regulations on the sole and dual use of cigarettes and smokeless tobacco products.

Marketing, FDA Communication, Tobacco Perceptions and Use in Addiction Treatment

Over four million individuals receive some type of addiction treatment annually; in this vulnerable population, smoking rates are high (67-75%) and resistant to tobacco control efforts. Because these individuals are highly likely to smoke, they are also likely to try, use, and adopt emerging and potentially modified risk tobacco products (e.g., e-cigarettes, snus, and smokeless tobacco). Working in collaboration with the National Institute on Drug Abuse (NIDA) Clinical Trials Network, investigators will identify a national random sample of 25 addiction treatment programs where 3,000 patients (1,000 patients per year for three years) plus 25 program directors will be recruited; using web-based computer-assisted strategies, participants will be interviewed concerning use of traditional and emerging tobacco products, exposure to federal tobacco education efforts and industry marketing campaigns, risk perceptions related to a range of tobacco products, and tobacco use behavior. Project goals are to understand tobacco product use, marketing, messaging, and perceptions in addiction treatment populations, and to inform regulatory activities that reduce tobacco use and risks in this vulnerable population. Specific aims are: (1) to assess the prevalence, and changes in prevalence over time, of smoking and use of alternative tobacco products in this population; (2) to assess exposure, and changes in exposure over time, to FDA tobacco-related communications, the role of the FDA, and tobacco marketing, and to examine the relationship of these exposures to risk perceptions regarding tobacco products and their use; and (3) to assess relationships between exposure to FDA communications, tobacco marketing, and perceived tobacco risk and health services measures (tobacco-related attitudes and utilization of tobacco cessation services) and tobacco behavior outcomes (prevalence, quit attempts, cigarettes per day).

Manipulating Tobacco Constituents in Female Menthol Smokers

The FDA has the regulatory authority to reduce nicotine levels and ban menthol in cigarettes, but has yet to take either of these actions. Available evidence suggests that women are more sensitive to the non-nicotine aspects of smoking (such as taste and smell) and may have a harder time quitting than men. The purpose of this study is to examine the effects of reducing nicotine content and/or removing menthol from cigarettes on measures of smoking behavior, nicotine dependence and cigarette abstinence in 320 female menthol smokers aged 18 and older. Investigators will examine the effects and safety of these two possible regulatory actions alone and in combination by randomizing subjects to one of four alternatives: reduced nicotine content (0.07 mg) cigarettes without menthol; reduced nicotine content (0.07 mg) menthol cigarettes; conventional nicotine cigarettes without menthol; or own brand (conventional nicotine menthol cigarettes). Specific aims are: (1) to examine the effects of reducing nicotine content and/or removing menthol from cigarettes on measures of smoking behavior, nicotine dependence and abstinence; (2) to examine the effects of reducing nicotine content and/or removing menthol from cigarettes on measures of toxicant exposure (e.g, cotinine, exhaled carbon monoxide, and urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL]) and other tobacco-specific nitrosamines; (3) to examine the mechanisms by which cigarette content manipulations may decrease smoking behavior in female menthol cigarette smokers; and (4) to explore the moderating effect of “supertaster status” (i.e., the tendency to experience flavors and irritation with far greater intensity than average) on tolerability of experimental cigarettes, smoking satisfaction, and smoking behavior. This study will provide new information about the impact of menthol and reduced nicotine content cigarettes in this vulnerable population.

Influence of Advertising and Product Type on E-Cigarette Demand among Smokers

Some new and emerging tobacco products may be less harmful than cigarettes, but research is needed to examine the extent to which broader adoption of these products could impact the public health. In this project, investigators will use an experimental auction method to study willingness to pay for various e-cigarette products that offer different features and costs. Investigators will assess which smokers may be more likely to purchase reusable versus disposable e-cigarettes and how print and television advertising impacts each of these preferences. Investigators will follow auction participants for up to six months to examine whether they continue to independently purchase and use the products obtained in the auction and the extent of dual use with or substitution for cigarettes. Specific aims are: (1) to examine the influence of product composition and print and television advertising on willingness to pay for e-cigarettes and cigarettes in the context of an experimental auction; and (2) to examine the extent to which e-cigarettes obtained in the auction are used as a supplement to or substitute for cigarettes. This project will provide new information regarding the factors affecting consumer demand for e-cigarettes and will offer important insights into the adoption process underlying product switching.

Behavioral and Neural Response to Reduced Nicotine Cigarettes in Young Smokers

The optimal cigarette nicotine content that would reduce tobacco dependence while still alleviating nicotine craving and withdrawal symptoms and the effects of nicotine content reductions on large smoker subpopulations are critical issues that could inform FDA tobacco product regulation. The goal of this project is to test the effects of reduced nicotine content cigarettes in 40 young adult daily smokers (aged 18-25 years). Investigators will compare the responses to smoking research cigarettes with four levels of nicotine content (<0.05, 0.1, 0.282, or 0.68 mg nicotine) and preferred cigarette brand smoked as the first cigarette of the day in the context of the following specific aims: (1) to obtain self-report ratings of the smoking experience, relief of craving and withdrawal, and affect; (2) to measure how the different cigarettes affect attention and neural biomarkers of withdrawal and executive functioning; and (3) to measure how the different cigarettes affect neural biomarkers of craving and its regulation. Functional magnetic resonance imaging (fMRI) will be used to provide a brain biomarker of response to the different nicotine yields, which can further elucidate subjective and cognitive effects. Findings will provide novel data that may inform decision-making regarding a standard for cigarette nicotine content.

Assessment of Tobacco Product Pharmacology and Behavior in Humans: Behavioral Pharmacology Associated with Cigar Smoking

Although many studies have investigated the effects of cigarette smoking on human behavior and biomarkers of exposure, our knowledge of how cigar smoking affects human behavior and pharmacology remains limited. The goal of this project is to better understand the dependence behaviors and biomarkers of exposure associated with cigar use. In 66 adult cigar-only smokers, the investigators will conduct a clinical study measuring dependence (both real and perceived), withdrawal relief, and craving using existing and modified behavioral scales and assessments. In addition, investigators will gather data on participants’ smoking topography (including latency to first puff, puff number, interpuff interval, and smoking duration) associated with smoking their usual type and brand of cigar, self-reported inhalation behaviors, and exhaled carbon monoxide. Investigators will also collect urine and blood samples to measure biomarkers of exposure (including nicotine, cotinine, and total NNAL).  The study will compare the dependence behaviors and pharmacology associated with the use of small versus large cigars, as well as biomarkers of exposure in cigar smokers who are and are not former cigarette smokers. This study will yield information on dependence behaviors and biomarkers of exposure associated with cigar smoking and may provide critical information on the impact of these tobacco products on the public health.

Measure Acrolein in Cigarettes

A chemical analysis is required to evaluate the harmful and potentially harmful constituents (HPHCs) present in mainstream cigarette smoke. The goal of this project is to measure acrolein quantities in the mainstream smoke produced from a variety of cigarettes currently marketed in the US. A total of 35 cigarettes will be examined under both the International Organization of Standardization (ISO) and Canadian Intense (CI) smoking regimens.  The results may be used to inform HPHC-related regulatory activities. (Project completed in 2014.)

Tobacco Lab Analysis-Carbonyl Measurements in Mainstream Cigarette Smoke

Carbonyls are formed during the combustion of tobacco products, and many are included on FDA’s list of harmful and potentially harmful constituents (HPHCs). The purpose of this project is to measure quantities of carbonyls using a validated testing method in a variety of cigarettes currently marketed in the US. A total of 35 different cigarette products will be examined under both the International Organization of Standardization (ISO) and Canadian Intense (CI) smoking regimens. The results may be used to inform HPHC-related regulatory activities.

Point-of-Sale Strategic Concept Testing – Focus Groups with Current Adult Smokers

Tobacco industry marketing efforts occur at the point-of-sale (i.e., at retail stores where tobacco is sold); point-of-sale marketing is associated with smoking experimentation, unplanned tobacco purchases, and urges to smoke. The goal of this project is to assess strategic concepts for a point-of-sale campaign to encourage tobacco cessation. The campaign’s target audience is current cigarette smokers (ages 25-54) who have made an attempt to quit smoking within the past year. Specific aims are: (1) to determine strategic concepts that resonate most with the target audience, and (2) to provide a deeper understanding of how to optimize messaging that can encourage and support smoking cessation. To accomplish this, 24 focus groups will be conducted with up to 144 participants who fit the target audience. Focus group participants will be asked to respond to a range of topics, including questions about their in-store cigarette purchasing behaviors, personal experiences with quit attempts, and emotional and cognitive reactions to the strategic concepts. This study is the first part of a phased approach to formative research that will inform a point-of-sale tobacco cessation campaign designed to encourage future quit attempts.

A-TRAC TCORS: Perception of Tobacco Use in Vulnerable Populations

Youth, women, low socioeconomic status populations, and racial/ethnic minorities are especially vulnerable to tobacco use. Data documenting use, addiction and perception among these groups are limited, and little information is available on best-practice tobacco risk communication campaigns for targeted populations. This project will assess tobacco use patterns, perceptions, attitudes, beliefs and communication channel use among African-Americans, Hispanics, and youth to determine strategies likely to be effective in communicating information on tobacco use risks, and will implement a communication intervention to facilitate quit attempts and cessation. Investigators will conduct 6-12 focus groups (with 8-10 participants per group) to examine channel use frequency (i.e., the most frequent channels for seeking tobacco-related communications and for communicating with others about tobacco) and the influence of factors that modify channel use, including age (i.e., 11-14.4 years, 14.5-18 years), gender, tobacco knowledge, and family and peer tobacco use. Investigators will also develop health communications targeted for different ethnic and socioeconomic groups and test them in 600-800 individuals in appropriate communities. Investigators will study the behavioral aspects of consumption of all forms of tobacco products, including smokeless products and new and emerging products. Specific aims are: (1) to examine the clinical and non-clinical correlates and outcomes (including cardiovascular outcomes) associated with tobacco use in blacks and Hispanics, using data from the Jackson (Mississippi) Heart Study and the Hispanic Community Health Study/Study of Latinos; (2) to evaluate communication channel use, knowledge, risk perception, and tobacco use intention; and (3) to implement a communication intervention to support tobacco use quit attempts and cessation among specific populations vulnerable to tobacco use. This project will generate data that can inform optimal tobacco risk communication campaigns that target vulnerable minority populations.

A-TRAC TCORS: Cardiovascular Injury Due to Tobacco Use

Tobacco smoke and tobacco products contain many harmful and potentially harmful constituents (HPHCs) that affect different organ systems and physiological processes. Therefore, an organ-systems approach is the preferred model to understand the adverse health consequences of tobacco use and to reduce tobacco-associated disease. The goal of this project is to understand the cardiovascular effects of tobacco products, with emphasis on early preclinical changes and their subsequent impact on health outcomes. Investigators will determine which cardiovascular disease (CVD) biomarkers are associated with specific measures of tobacco exposure and what magnitude of change in these biomarkers translates into a clinically meaningful impact on CVD outcomes. Specific aims are: (1) to elucidate the relationship between biomarkers of cardiovascular dysfunction/injury and specific measures of exposure to tobacco smoke and smokeless tobacco, by evaluating biomarkers of endothelial damage and predilection for thrombosis in a cross-sectional study of 480 smokers, smokeless tobacco users, and non-smokers without overt CVD (aged 26-45); (2) to identify and compare the dose-dependent associations between tobacco use, measures of subclinical cardiovascular disease, and clinical cardiovascular events, using data from the Multi-Ethnic Study of Atherosclerosis (which includes 6814 participants aged 45-84); and (3) to validate candidate biomarkers associated with tobacco exposure in independent human cohorts, using data from the Jackson Heart Study (which includes 5,301 African American residents of Jackson, Mississippi, aged 35-84). This project will improve the understanding of the cardiovascular consequences of tobacco use, particularly among vulnerable minority populations.

Communicating the Risks of Harmful Cigarette Smoke Constituents

New information about tobacco smoke constituents will have an uncertain impact on smoker behavior. It may prompt smokers to quit, or it may prompt them to switch to brands they perceive as less harmful and possibly smoke more. This project will identify the impact of new constituent information on smokers’ risk beliefs and cigarette smoking; all studies and focus groups will include representation from vulnerable populations, including adolescents, low income populations, African-Americans, Hispanics, gays, lesbians, and bisexuals. Specific aims are: (1) to identify cigarette smoke constituents that adolescents (aged 13-17) and adults (aged 18-65) find threatening and discourage them from wanting to smoke, by conducting 10 focus groups (with approximately 7-10 participants each) and a population-based telephone survey of 800 adolescents and 3800 adults; (2) to develop a library of cigarette smoke constituent risk messages that have been vetted in 14 focus groups (approximately 10 participants each) of adult and adolescent smokers and non-smokers and tested in 2654 Internet survey participants; and (3) to determine which pack labels most effectively increase adult smokers’ cessation behaviors in a randomized controlled trial of 672 adult smokers. The results of this project may inform decisions regarding the type and placement of constituent-related health messages on cigarette packaging.

American Heart Association Tobacco Regulation and Addiction Center (A-TRAC)

This virtual Center will study the cardiovascular toxicity of tobacco products and the relationship between tobacco product use and subclinical progression of cardiovascular disease (CVD) in order to identify biomarkers of cardiovascular injury related to tobacco product exposure. Studies will identify specific domains of cardiovascular injury that are sensitive to tobacco exposure, facilitate the identification of harmful and potentially harmful constituents (HPHCs), and measure the impact of these constituents on cardiovascular disease outcomes. In cohorts of varying ethnicities, investigators will study behavior, perceptions, and attitudes regarding tobacco products in order to identify which communications channels are used by vulnerable populations to obtain information about tobacco products, as well as strategies that are likely to be effective in discouraging initiation and continuation of tobacco use. Project 1 will identify biomarkers of tobacco product exposure and relate them to biomarkers of cardiovascular injury in a well-controlled animal model; to determine the relationship between these two sets of biomarkers, investigators will identify metabolites of tobacco constituents, establish their relationship with the extent and duration of exposure, and determine how they are related to the extent of cardiovascular injury. Project 2 will determine which CVD biomarkers are associated with specific measures of tobacco exposure and what magnitude of change in these biomarkers translates into a clinically meaningful impact on CVD outcomes. Project 3 will evaluate the tobacco use pattern, clinical and non-clinical correlates, outcomes, and knowledge/perceptions among vulnerable populations (i.e. African-Americans, Hispanics, and youth), generating data that can inform optimal tobacco risk communication campaigns that target vulnerable minority populations.

A-TRAC TCORS: Cardiovascular Toxicity of Tobacco Products

Tobacco use is associated with an increase in cardiovascular disease risk factors; however, tobacco constituents that mediate the cardiovascular toxicity of tobacco use remain largely unknown. Biomarkers of tobacco-induced cardiovascular injury associated with exposure to cigarette smoke, smokeless tobacco and their constituents may inform the FDAs regulation of tobacco products to protect public health. This project will identify biomarkers of tobacco product exposure and relate them to biomarkers of cardiovascular injury in a well-controlled animal model. To determine the relationship between these two sets of biomarkers, investigators will identify metabolites of tobacco constituents, establish their relationship with the extent and duration of exposure, and determine how they are related to the extent of cardiovascular injury. Specific aims are: (1) to examine tobacco-induced endothelial injury in adult mice exposed to varying intensities of tobacco smoke and smokeless tobacco; and (2) to delineate the contribution of harmful and potentially harmful (HPHC) constituents, such as aldehydes, to endothelial injury induced by tobacco exposure, by examining changes in endothelial injury biomarkers in mice exposed to individual constituents (i.e., nicotine, acrolein and crotonaldehyde). This project will provide information regarding how tobacco products could be evaluated for cardiovascular toxicity and how product constituents might be regulated to reduce the risk of cardiovascular injury.

Effective Risk Communication on New and Emerging Tobacco

Current evidence is limited on consumer knowledge and perceptions of risks related to new and emerging tobacco products and the messages that most effectively increase perceptions of risk. This project will evaluate the impact of health warnings for new and emerging tobacco products (e.g., e-cigarettes, hookah tobacco, cigarillos/little cigars) on adolescents, young adults, and the gay, lesbian and bisexual population. Specific aims are: (1) to identify perceived risks of, knowledge about, and attitudes towards harmful constituents and health risks of cigarettes and new and emerging tobacco products in 800 adolescents (aged 13-17) and 800 young adults (age 18-25) to inform development of product-specific risk messages; (2) to develop risk messages for each product that increase risk perceptions among adolescents and young adults, by conducting an Internet survey of 400 adolescents and 400 young adults; and (3) to establish the real-world impact of product risk messages (developed in Aim 2) appearing at the point-of-sale on risk perceptions, attitudes, knowledge, susceptibility and quit intentions of adolescents and young adults. This study will provide information about how best to inform youth and young adults about the health risks associated with using a variety of tobacco products.

OSU Center of Excellence in Regulatory Tobacco Science (OSU-CERTS)

The goal of this Center is to understand the reasons for tobacco product preferences, especially related to dual and poly-use, and how these reasons influence use in a diverse, ever-changing tobacco product environment. The Center will conduct four projects involving both rural (Appalachian Ohio) and urban (Columbus, Ohio) adolescents and adults. Projects 1 and 2 will use a three-year cohort of adolescents and their families to establish and compare (1) the prevalence of smoking, smokeless tobacco use and dual use, and (2) tobacco use risk factors, with an emphasis on environment, advertising and marketing, and trajectories to regular use. Studies will include an assessment of carcinogen exposure and genetic factors for taste perception and tobacco use behavior. Project 3 will establish a three-year cohort of adults to characterize the diversity of tobacco products used over time and examine individual, cognitive and affective risk factors; the project will evaluate purchasing factors and marketing practices in retail environments. Project 4 will include several experimental studies that examine psychological constructs and decision-making models for choosing tobacco products.

OSU TCORS: Understanding Adolescent Trajectories, Exposures and Susceptibilities

Most smokers and smokeless tobacco (ST) users initiate use prior to the age of 18. ST use among adolescents has been increasing and the prevalence of dual use of ST and cigarettes is especially high in Ohio. However, almost nothing is known about adolescent initiation of ST and dual use, trajectories to regular use and dependence, exposures through biomarkers, and environmental and genetic risk factors. Investigators will survey 1050 rural and 1050 urban Ohio males aged 11-14 and analyze oral rinses and urine samples to evaluate trajectories from experimentation to regular use and dependence, degree of nicotine exposure with biochemical confirmation, and level of nicotine dependence; investigators will also measure carcinogen exposures and consider various genetic risk factors. Specific aims are: 1) to determine the time from experimentation to regular use of and dependence on various tobacco products (including cigarettes, chew, snuff, snus, and dissolvables), based on product nicotine levels and adjusted for environmental predictors of initiation (e.g., family and peer tobacco use, advertising and media); 2) to determine the differences in tobacco toxicant exposure among daily or near-daily ST users, smokers, and dual users using conventional and novel biomarkers of exposure (e.g., metabolomics); and 3) to identify genetic susceptibilities that influence ST use, smoking and dual use (i.e., nicotine metabolic ratio and genes associated with nicotine metabolism, neurobehavior and taste perception), using mouthwash samples from 2570 adolescents and 4626 parents. This project will provide new information about tobacco use trajectories among youth with regard to ST and dual use.

OSU TCORS: Urban and Rural Male Youth Cohort Study of Tobacco Use

The rate of smokeless tobacco (ST) use among high school males in Ohio is nearly twice as high as the national rate, and dual use with cigarettes is common; with new products on the market and marketing efforts targeting urban users and smokers, youth may be even more likely to initiate ST and dual use. In this three-year project, investigators will examine male youth initiation of ST (i.e., chew, snuff, snus, and dissolvables) and dual use, as well as the marketing, advertising and other environmental factors that may contribute to initiation, by administering self-report questionnaires to a cohort of 1050 rural and 1050 urban Ohio males aged 11-14 and their families. Specific aims are: (1) to examine how cognitive and affective responses and attitudes towards tobacco advertisements relate to ST and dual use initiation; 2) to examine how exposure to tobacco marketing and level of smoking media literacy relate to ST and dual use initiation; and 3) to conduct a ten-day exploratory study using ecological momentary assessment (EMA) to compare real-time exposures between tobacco users and nonusers. Findings from this project will provide new information about why youth initiate ST and dual use of ST and cigarettes.

OSU TCORS: Diversity of Tobacco Products Used and Purchased

Dual use of cigarettes and smokeless tobacco (ST) products is becoming more common. However, stable estimates of dual use prevalence are difficult to ascertain, as studies have used differing operational definitions (i.e., frequency of use and type of tobacco product) to describe behavior. This project involves a longitudinal characterization of diverse product preferences among a cohort of 796 Ohio adults (aged 18 and older) who are exclusive smokers (using cigarettes, little cigars, and/or cigarillos), exclusive ST users (using chew, snuff, and/or snus), and dual users at baseline; participants will be interviewed at baseline and every six months over a three-year period. Specific aims are: 1) to compare tobacco product use (i.e. combustible, ST, new and emerging products) between rural and urban adults who are smokers, ST users, and dual tobacco users at baseline; 2) to compare associations between product use and various factors, including individual factors (i.e. dependence, previous quit attempts, stage of change, cessation interest/efficacy, household smoking, home and work indoor air policies), cognitive and affective factors (i.e., risk perceptions, risk-reduction beliefs), and purchasing factors (brand loyalty, price promotions); and 3) to determine the association between purchasing factors (i.e., exposure to coupons, multi-pack specials, special discounts at point-of-sale tobacco retail outlets, and brand loyalty) and product use among subsets of rural and urban users. This project will provide information about the prevalence of cigarette use, ST use and dual use in adults and the individual and environmental factors associated with product use.

OSU TCORS: Comprehension of Health Risks in More and Less Arousing Affective Contexts

Prior research suggests that the affect (e.g., goodness vs. badness, calming vs. exciting) aroused by health messages is a critical factor in tobacco users’ long-term understanding of risk, and, therefore, in influencing quit intentions and usage. Investigators will evaluate the role of affective arousal in increasing cigarette warning label effectiveness and in making products appear less risky in brand advertising and promotion in smokers; affect will be manipulated through graphic images of health effects and smoking cues (e.g., a lit cigarette). Specific aims are: (1) to test the effects of graphic images that vary in arousal on smoker understanding of text-based smoking risk information; investigators will randomize adult smokers and adolescent smokers to an image condition that varies in arousal (no image, low, medium, or high arousal) and to a time point (immediate, one week, or six weeks) to test risk understanding, perceptions, and use; (2) to use a similar experimental design to examine arousal effects on long-term understanding of numerically-expressed health risks; investigators will test absolute vs. relative risks (in adult and adolescent smokers) and percentage vs. frequency formats (in adult smokers); and (3) to examine the effects of the presence/absence of pro-tobacco smoking cues on adult and adolescent smokers’ understanding of health risks at exposure and one and six weeks. This research will provide new information about how to present cigarette warning label health information in ways that maximize user understanding.

Improved Models to Inform Tobacco Product Regulation (UCSF TCORS)

This Center will study (1) the economic impacts of tobacco use on health costs; (2) risk perceptions, perceived acceptability, consumer responses to pro-tobacco marketing and anti-tobacco messages and other behavioral and social determinants of tobacco use; and (3) rapid changes in risk due to tobacco use and secondhand smoke exposure as manifested in cardiovascular and pulmonary dysfunction, allowing the identification of functional biomarkers of acute cardiopulmonary responses to tobacco use. Project 1 will develop microeconomic models to characterize the impact of changing tobacco product use on tobacco-related disease and healthcare costs. Project 2 will use a longitudinal cohort design to study the role of adolescents’ and young adults’ risk and benefit perceptions related to tobacco use, marketing, and control. Project 3 will study smokeless tobacco use among rural high school males. Project 4 will quantify, and identify biomarkers of, the short-term pulmonary effects of smoking and secondhand smoke exposure. Project 5, a cardiovascular assessment of the effects of tobacco and nicotine, will involve controlled short-term exposures of human subjects to test products that provide a wide range of nicotine, particle and other cardiovascular toxin concentrations to determine how these components adversely affect cardiovascular risk.

UCSF TCORS: The Impact of Changing Tobacco Product Use on Tobacco-Related Disease and Healthcare Costs

Current models of the health-related economic costs of cigarette smoking reflect the complex relationship between smoking, health, and healthcare expenditures; however, research on healthcare costs attributable to the use of tobacco products other than cigarettes is lacking. This project will use individual-level data from national surveys to develop microeconomic models that estimate and compare tobacco-related healthcare costs. Specific aims are: (1) to develop microeconomic models to estimate the healthcare costs attributable to the use of different tobacco products (e.g., cigarettes, menthol cigarettes, cigars, moist snuff, chewing tobacco) to determine whether product type substantially affects costs; (2) to develop microeconomic models to estimate the healthcare costs attributable to secondhand smoke exposure; (3) to evaluate the impact of potential FDA regulations on healthcare costs due to projected changes in tobacco use and secondhand smoke exposure, using a time series analysis with national survey data, longitudinal model analysis of Population Assessment of Tobacco and Health Study (PATH) data, simulations of tobacco use prevalence changes, and simulations of short-term pulmonary and cardiovascular disease risk. This project will provide improved models of the costs associated with cigarette smoking and the use of other tobacco products, which will be useful for analyzing the economic impact of potential FDA regulations.

UCSF TCORS: The Role of Risk and Benefit Perceptions in Tobacco Control and Product Usage

Prospective longitudinal studies using comprehensive measures of tobacco use, perceptions and marketing are needed to provide specific scientific evidence about how marketing shapes decisions to use and stop using different tobacco products. This project will use a longitudinal cohort design to study the role of adolescents’ and young adults’ risk and benefit perceptions related to tobacco use, marketing, and control. Investigators will develop and test a comprehensive model concerning the relationships among pro- and anti-tobacco marketing messages, perceptions of tobacco risks and benefits, perceived product acceptability, and patterns of tobacco use. Subjects will include 1000 ninth graders (age 14) followed through high school and 1000 twelfth graders (ages 17-18) followed into young adulthood. Specific aims are: (1) to determine adolescents’ and young adults’ perceptions of risk (for disease, addiction, and death), acceptability, and benefits of using conventional, new, and emerging tobacco products (e.g., cigarettes, e-cigarettes, little cigars, cigarillos, smokeless tobacco, snus, dissolvables, compressed tobacco); (2) to determine the predictive relationships among perceptions of tobacco product risks, benefits, and acceptability and the onset, continuation, cessation, relapse, switching, and dual use of tobacco products; and (3) to identify contextual factors (exposure to pro-tobacco media, anti-tobacco media, warning labels, and smoking images) that influence perceptions of risks, benefits, acceptability, and subsequent tobacco use. This study will contribute to the understanding of how tobacco marketing impacts risk perceptions and tobacco use among adolescents and young adults.

UCSF TCORS: Smokeless Tobacco Use among Rural High School Males and Resulting Nicotine and Carcinogen Exposure

Smokeless tobacco (ST) use among US high school students is much higher among males and is especially high in rural areas. Data regarding the addictive potential and nicotine and carcinogen exposure in adolescents using new ST products alone or in dual use with cigarettes is needed. This clustered longitudinal observational study of 1000 rural adolescent male baseball athletes will use web-based surveys and saliva specimen analysis to provide information about the cognitive and social determinants of use (and non-use) of conventional ST products, new ST products (e.g., snus, dissolvables), dual use with cigarettes, and use of other alternative products (e.g., e-cigarettes, cigarillos, hookah/waterpipe). In addition, the impact of exposure to marketing and anti-tobacco messages (e.g. graphic warning labels) on risk and benefit perceptions, change in ST use status (i.e., experimentation, initiation, relapse, switching, and cessation) and actual exposure to nicotine and carcinogens will be evaluated over time. Specific aims are: (1) to measure patterns and determinants of conventional and new ST product use and dual/poly use with cigarettes over time; (2) to measure exposure to tobacco marketing and anti-tobacco messages and their association with ST use, perceived risks and benefits of use, and future expectations of ST and dual/poly use over time; (3) to use existing and new biomarkers to evaluate nicotine and carcinogen exposure and their association with nicotine metabolism rate in ST and dual users; and (4) to identify factors in addition to product type and brand that predict nicotine and carcinogen exposure (e.g., measures of risk and benefit perception, nicotine metabolism rate). This study will enhance the understanding of the relationship of marketing exposure to risk and benefit perceptions, tobacco use status, and intentions to use conventional and new ST products and their dual use with cigarettes in a population at high risk of use.

UCSF TCORS: Quantification and Biomarkers of Short-Term Pulmonary Effects of Tobacco Smoke Exposure: Infection-Related Acute Lung Injury

Additional research is needed to evaluate the link between smoking and acute lung injury (ALI), a common cause of acute respiratory failure in critically ill patients. This project will quantify, and identify biomarkers of, the short-term pulmonary effects of smoking and secondhand smoke exposure. Investigators will collect plasma specimens from 570 critically ill patients with severe infection (aged 18 and older) to measure biomarkers of cigarette smoke exposure and lung epithelial and endothelial injury, and will evaluate the impact of cigarette smoke exposure in mouse models. Specific aims are: (1) to quantify the strength, dose-response curve, and time course of the association between cigarette smoke exposure, as measured by validated biomarkers, and the development of ALI in patients admitted to the hospital with severe infection; (2) to test the effects of cigarette smoke exposure and varying nicotine content on the development of infection-related ALI in mouse models, with a focus on identifying plasma biomarkers of tobacco-related lung epithelial or endothelial injury that can then be tested in critically ill patients; and (3) to validate the association between biomarkers of tobacco-related lung epithelial and endothelial injury and the development of ALI in critically ill patients with severe infection. The results of this project will inform more accurate models of the economic and public health effects of cigarette smoke exposure. In addition, these data will identify biomarkers of tobacco-related ALI that may be used in future toxicity studies.

UCSF TCORS: Cardiovascular Assessment of the Effects of Tobacco and Nicotine Delivery Products

The cardiovascular risks of secondhand cigarette smoke, smokeless tobacco (i.e., moist snuff), and e-cigarettes are not adequately understood. This project, a cardiovascular assessment of the effects of tobacco and nicotine, will involve controlled short-term exposures of 88 adult smokers and nonsmokers (aged 21-50) to test products that provide a wide range of nicotine, particle and other cardiovascular toxin concentrations to determine how these components adversely affect cardiovascular risk. Assessment methods will include flow-mediated dilation, heart rate measurement, thromboelastography, Doppler testing, digital vasoconstriction testing, peripheral arterial tonometry, and blood biomarker measurement, and others. Specific aims are: (1) to determine the relative contributions of nicotine and combustion products to the cardiovascular risk associated with active cigarette smoking; (2) to determine which cardiovascular risk biomarkers are affected by exposure to low concentrations of other constituents and secondhand smoke; (3) to determine the cardiovascular risk of smokeless tobacco use; and (4) to determine the cardiovascular risk of electronic cigarettes and the respective contributions of nicotine and electronic cigarette vapor. New biomarkers that can detect differences in the cardiovascular safety of various tobacco products may help inform FDA regulation of conventional, new and emerging products.

Effective Communication on Tobacco Product Risk and FDA Authority (Center for Regulatory Research on Tobacco Communication)

This Center will use communication science to improve messages about cigarette smoke constituents, emerging tobacco products, and the FDA’s regulatory authority over tobacco products. The Center’s scientific aims are: (1) to characterize the public’s awareness and beliefs about tobacco products and FDA regulatory authority through mixed methods approaches, using focus groups and multiple population-based telephone surveys; (2) to create potent messages regarding risk and FDA authority; and (3) to conduct randomized controlled trials that assess message impact on tobacco use intentions and behaviors in real-world contexts. Project 1 will determine the effectiveness of different constituent labels/messages on cigarette packs with regard to changing perceived risk and altering cessation behavior. Project 2 will evaluate the impact of health warnings for new and emerging tobacco products not yet regulated by FDA, including e-cigarettes, hookah tobacco, and cigarillos/little cigars on adolescents and young adults. Project 3 will test FDA communication messages regarding regulatory authority over tobacco products in order to assess how to improve the credibility of these messages in targeted populations. All studies will oversample vulnerable populations with high rates of smoking (Black, Hispanic, gay, lesbian, bisexual, low income) as well as adolescents and young adults who are at greatest risk for tobacco use initiation.

UNC TCORS: Enhancing Source Credibility in Tobacco Regulatory Communications

New communications about the dangers of smoking and the benefits of quitting can help improve the public health, but little research exists about how to frame and deliver these messages most effectively. This project will test FDA messages regarding its regulatory authority over tobacco products in order to assess how to improve message credibility in targeted populations. Specific aims are: (1) to characterize perceptions of the FDA in terms of its regulatory authority, credibility, and tobacco control communication campaigns among adolescents (aged 13-17), young adults (aged 18-25) and adults (aged 26-65), and among vulnerable populations (African American and gay, lesbian, and bisexual), in seven focus groups (7-10 participants each) and phone surveys of 3800 individuals; (2) to use FDA messages to experimentally examine three determinants of source credibility (i.e., source sponsor, source depiction and source engagement) to create optimally-framed messages and test them among current smokers (participating in ten focus groups and 300 interviews); and (3) to conduct a randomized controlled trial of 352 young adult and adult smokers to test the hypothesis that optimally-framed (i.e., high source credibility) FDA cigarette constituent messages will increase intentions to quit more than suboptimally-framed (i.e., no source attached) cigarette constituent messages. This research will provide information regarding the effectiveness and credibility of FDA communication campaigns that convey the health risks of cigarette use.

UCSF TCORS: The Role of Risk and Benefit Perceptions in Tobacco Control and Product Usage

Prospective longitudinal studies using comprehensive measures of tobacco use, perceptions and marketing are needed to provide specific scientific evidence about how marketing shapes decisions to use and stop using different tobacco products. This project will use a longitudinal cohort design to study the role of adolescents’ and young adults’ risk and benefit perceptions related to tobacco use, marketing, and control. Investigators will develop and test a comprehensive model concerning the relationships among pro- and anti-tobacco marketing messages, perceptions of tobacco risks and benefits, perceived product acceptability, and patterns of tobacco use. Subjects will include 1000 ninth graders (age 14) followed through high school and 1000 twelfth graders (ages 17-18) followed into young adulthood. Specific aims are: (1) to determine adolescents’ and young adults’ perceptions of risk (for disease, addiction, and death), acceptability, and benefits of using conventional, new, and emerging tobacco products (e.g., cigarettes, e-cigarettes, little cigars, cigarillos, smokeless tobacco, snus, dissolvables, compressed tobacco); (2) to determine the predictive relationships among perceptions of tobacco product risks, benefits, and acceptability and the onset, continuation, cessation, relapse, switching, and dual use of tobacco products; and (3) to identify contextual factors (exposure to pro-tobacco media, anti-tobacco media, warning labels, and smoking images) that influence perceptions of risks, benefits, acceptability, and subsequent tobacco use. This study will contribute to the understanding of how tobacco marketing impacts risk perceptions and tobacco use among adolescents and young adults.

The Impact of Tobacco Exposure on the Lung’s Innate Defense System (UNC TCORS)

This Center will study the potential adverse impact of tobacco alternatives (e.g., little cigars and hookah/waterpipe tobacco) on the lung’s innate defense system; using human and mouse in vivo and in vitro models, this project will identify novel biomarkers associated with tobacco-induced changes in lung innate defense, which can be applied to understand the potential toxicity of new and emerging tobacco products. Projects I and 2 will determine the impact of tobacco products on specific aspects of this system (i.e., airway surface liquid homeostasis and mucin/mucus); investigators will use an innovative in vitro smoke exposure system to measure specific biomarkers of innate lung defense and will obtain airway samples from smokers of alternate tobacco. In Project 3, investigators will develop a novel mouse model of smoke exposure that more closely mimics the chronic bronchitis phenotype seen in humans with COPD. This model will be used to validate tobacco exposure biomarkers seen in Projects 1 and 2 as well as to determine epigenetic changes following in vivo exposure to alternative tobacco. Project 4 will determine genomic biomarkers of smoke exposure associated with tobacco products from samples obtained from human volunteers; focusing on changes in antiviral host defense in these subjects, this model will be used to integrate observations made in the other projects with findings obtained from humans infected with live attenuated influenza virus.

UNC TCORS: The Effects of New and Emerging Tobacco Products on Lung Hydration and Inflammation

Airway surface hydration is critical to normal lung function and defense against disease. This project will identify the tobacco smoke constituents and the emerging tobacco products that inhibit the epithelial mechanisms that maintain airway surface hydration. Investigators will systematically compare the hydration responses (mucus/airway surface liquid [ASL] volume) of airway epithelia to new and emerging tobacco products and their constituents; they will also assess whether markers of ASL volume homeostasis constitute novel biomarkers of tobacco exposure. Experiments will use human bronchial airway epithelial cells and lung tissue obtained from transplanted donor lungs or donor lungs not suitable for transplantation. Specific aims are: (1) to determine which chemicals in tobacco smoke affect ASL nucleotide levels, ASL volume, and unfolded protein response in a human bronchial epithelial culture system (using Kentucky reference cigarettes); (2) to determine the impact of new and emerging tobacco products (e.g., little cigars, hookah) on ASL homeostasis and unfolded protein response in well-differentiated human bronchial epithelial cultures; and (3) to assess ASL nucleotide levels, ASL volume, and unfolded protein response as in vivo biomarkers of product exposure. This project will provide new information about the impact of tobacco smoke and emerging tobacco products on the lung’s innate defense system.

UNC TCORS: The Effects of Tobacco Exposure on the Airway Proteome and Mucus/Mucin Integrity

Mucus is a complex network of mucins, antimicrobial peptides, enzymes and proteins that detect, immobilize, destroy, and/or remove a range of foreign bodies, toxins and pathological factors that would otherwise overwhelm the body’s defense system. Tobacco exposure dehydrates airway surfaces, and recent studies suggest that airway surface liquid (ASL) dehydration and reduced anion secretion may permanently alter mucin maturation. Investigators will analyze mucus from in vitro and in vivo models and from human subjects to identify novel biomarkers of tobacco exposure (mucomarkers) and to determine the effects of exposure to new and emerging tobacco products (e.g., flavored cigarettes, little cigars, hookah) on the expression of potential mucomarkers to assess the relative toxicology of these products. Airway epithelial cells will be derived from excess surgical pathology tissue from 63 elective surgery patients and from organ donor lungs not suitable for transplantation. Specific aims are: (1) to assess the impact of new and emerging tobacco products and their constituents on mucus/mucin biophysical and barrier properties, including their integrity, mucin polymeric structure, and maturation in mucus; (2) to identify mucomarkers in response to products with respect to both muco-proteome and mucin interactome in human bronchial cell cultures, mouse and human bronchoalveolar lavage fluid, and induced sputum; and (3) to test whether tobacco products change the proteins, messenger ribonucleic acid (mRNA), and microRNA (miR) contained in extracellular vesicles in responses to different tobacco products. This project will provide important information on the effect of tobacco exposure on mucus and its ability to protect airway surfaces.

UNC TCORS: Mouse Models of Smoking-related Diseases: What is the Best Mimic of Human Disease?

Most mouse models of tobacco smoke-related lung disease have produced evidence of mild-to-moderate emphysema but little or no evidence of chronic bronchitis, which is a large component of chronic obstructive pulmonary disease (COPD) in humans. This project will establish a novel mouse model of tobacco smoke-induced lung injury that mimics the chronic bronchitis phenotype seen in humans with COPD. Investigators will identify validated animal models that can establish standard toxicity changes and confirm what magnitudes correlate with changes in human health outcomes. Specific aims are: (1) to determine the effects of cigarette smoke on inflammatory and innate immunity, muco-ciliary and bacterial clearances, messenger ribonucleic acid (mRNA) and microRNA (miR) expression, and intracellular signaling pathways induced by 1-day, 5-day and 6-month exposure; and (2) to determine the effects of little cigars and other new and emerging tobacco products (e.g., hookah) on these same parameters induced by 1-day, 5-day and 6-month exposure. This project will provide new information about the adverse respiratory consequences of tobacco smoke and will inform FDA evaluation of new tobacco products.

UNC TCORS: Translational Studies to Identify Epithelial Biomarkers of Smoke Exposure

The respiratory epithelium is the primary target of most common respiratory viruses in humans. Cigarette smoke-induced changes in epithelial function have a significant impact on respiratory host defense and are important in determining the final outcome of infection; however, it is unknown whether tobacco alternatives (e.g., hookah, little cigars) have similar effects on epithelial host defense responses. This project will identify genomic biomarkers of smoke exposure associated with tobacco alternatives from nasal epithelial cell samples obtained from 240 adults (aged 18-45) and will evaluate respiratory host defense in subjects infected with live attenuated influenza virus. Specific aims are: (1) to use superficial nasal scrape biopsies to compare genomic and epigenomic signatures induced in epithelial cells following exposure to cigarette smoking and tobacco alternatives; (2) to use an in vitro model of differentiated human nasal epithelial cells to compare host defense responses following exposure to cigarette smoke and tobacco alternatives; and (3) to compare influenza-induced responses in cigarette smokers, hookah smokers, and e-cigarette smokers in vivo. This research will provide new information about the impact of new and emerging tobacco products on respiratory defense systems.

Tobacco Products and Atherosclerotic Disease

Cigarette smoking and, potentially, smokeless tobacco use are associated with an increase in cardiovascular disease (CVD) risk. Nevertheless, the tobacco constituents that mediate the cardiovascular toxicity of tobacco use remain unknown. Although several studies have examined the effect of cigarette smoke on surrogate markers of heart disease, the direct effect of tobacco smoke and smokeless tobacco on atherosclerosis, the underlying cause of CVD, has not been rigorously studied. Because CVD is a chronic disease that develops over several years, biomarkers of tobacco-induced cardiovascula