Dorothy K. Hatsukami - US grants

While its consequences are a major health problem, no treatment has proven consistently effective in eliminating smoking behavior. Evidence suggests this failure may be related in part to topographical factors in smoking, since certain types of smokers respond better to treatment than others. The proposed research will establish the reliability and validity of a new device for studying smoking topography. The device employs microcircuit technology to measure cigarettes/day and puffs/cigarette, as well as individual puff intervals, cigarette intervals, inter-puff intervals, and inter-cigarette intervals in subjects during their normal daily lives. Initial studies will be conducted under controlled hospital conditions using research cigarettes with known nicotine and other chemical composition to establish the reliability and validity of the portable recording device. Smoking topography will be determined for the same subjects under controlled hospital conditions and after hospital discharge, and will be used along with other measures to assess compliance in use of the smoking recorder. As part of the initial validation studies, the relation between the above topographical measures and total smoke exposure (volume of lung exposure) also will be ascertained. After completion of the initial studies, the smoking recorder will be used with subjects in their normal environment to determine treatment effects on smoking topography, in assessing the overall effectiveness of a common smoking treatment strategy. The research findings should improve our understanding of factors related to smoking treatment success, and have direct application to the development and evaluation of more effective treatment programs for the elimination of smoking behavior.

There is evidence suggesting that smokers persist in the use of nicotine gum beyond the recommended period of use. Furthermore, although the use of gum has improved the rate of successful smoking cessation, between 50-70% relapse to smoking. One of the factors which may contribute to the persistent use of gum or relapse to smoking may be the occurrence of withdrawal symptoms upon cessation of nicotine gum. We have spent the past several years determining valid, reliable and sensitive indicators of the tobacco withdrawal syndrome and how it is related to treatment outcome. The proposed research will extend our previous studies and examine signs and symptoms of withdrawal from nicotine gum and their relationship to treatment outcome. There will be four studies conducted over the course of four years. The first study will be a prospective and systematic examination of physiological, subjective, and behavioral reactions to nicotine gum cessation, and will compare the intensity and time course of signs and symptoms of withdrawal from nicotine gum with that of tobacco. The second study will be a prospective epidemiological survey which will determine the prevalence of nicotine gum withdrawal symptoms, determinates of severe withdrawal symptoms from nicotine gum, and the relationship between severity of nicotine withdrawal symptoms and relapse to smoking. The third study will examine the relationship between duration of nicotine gum use with severity of nicotine gum withdrawal symptoms and treatment outcome. The fourth study will examine the effect of gradual vs abrupt cessation of nicotine gum on severity of withdrawal symptoms and treatment outcome.

APPLICANT'S ABSTRACT: It is estimated that there are now about 6 million regular users of smokeless tobacco (snuff or chewing tobacco) in the United States. The rate of consumption of smokeless tobacco (SLT) is of particular concern due to the potential for addiction and physical dependence on SLT. Negative health consequences are also associated with the use of smokeless tobacco. Although many SLT users report wanting to quit, few well-controlled studies have been conducted examining treatments for SLT users. Of the previous studies, including our own that examined the effects of nicotine gum vs. placebo gum, the results have been dismal. We are asking for continuation of funds for the continuation of a current treatment study that examines the effects of primary and secondary reinforcement properties of smokeless tobacco on craving, withdrawal symptoms and treatment outcome. This study will involve a 2 x 2 design where subjects (N=400, 100 in each treatment condition) have been assigned randomly and in a semi-double blind fashion to one of four treatments: transdermal nicotine system (TNS; primary reinforcement) versus placebo; and mint snuff (non-nicotine product with secondary reinforcement properties) versus no-mint snuff. Also this study carefully and intensively examines factors associated with lapse and relapse situations and coping skills used to circumvent lapse or relapse in a random sample of subjects who are abstinent at the end of treatment. Continuation for funds for this study are requested since, upon the recommendations of the IRG, we increased our sample size (from 200 to 400) and extended the follow-up from 6 to 12 months. We made this modification with no increase in funding or time. The results from this study will provide a greater understanding of factors associated with dependence on SLT, an effective method for the treatment of SLT users and a greater understanding of factors which lead to or prevent relapse. This grant proposal will also run eight human laboratory experiments that will focus on factors that facilitate and minimize SLT use. A laboratory model will be systematically developed in which abstinent SLT users are exposed to smokeless tobacco-related stimuli and them required to work for tokens that can be exchanged for money or specific amounts of SLT. Factors that will be examined and considered to facilitate smokeless tobacco use will include longer lengths of abstinence, exposure to a priming dose of smokeless tobacco, use of alcohol, and food restriction. On the other hand, factors that will be examined and thought to minimize SLT use include TNS, nicotine gum and the availability of alternative reinforcers. These experiments will provide a laboratory model that will allow for a more systematic and efficient observation of factors associated with relapse and the manipulation of variables that may be effective in treatment.

Cocaine use has become an increasing concern over the past several years. More recently, cocaine use via the smoking route has gained prominence. The use of cocaine via this route have increased form 1% in 1977 to 18% in 1984. In spite of the dramatic increase, there have been very few studies which have examined the effects of cocaine via this route either in animals or humans. Furthermore, there has been little systematic research on factors which may affect or maintain self-administration of cocaine in humans. The goals of the proposed studies are to establish basic experimental procedures and to provide an understanding of the patterns and effects of cocaine use via several routes of administration as well as factors which affect its use. The unique characteristics of this grant proposal are: (1) the availability of a device to administer a controlled dose of smoked cocaine base and (2) the parallel studies which will be conducted in humans and monkeys. Human subjects will be housed in the General Clinical Research Center. The specific objective of the first study will be to compare the bioavailability, and the subjective and physical effects of smoked cocaine with that of intravenously and intranasally administered cocaine. Subjects will be randomly administered three dosed of cocaine and placebo across all three routes of administration. The goal of the second study is to examine the patter of self-administration of cocaine and to determine factors which initiate and maintain the use of cocaine (e.g., dose, plasma cocaine levels, subjective states, physiological states). Subjects will be given three doses of cocaine and placebo in repeated and randomized trials. The goal of the third study is to provide a quantitative measure of the effect of dietary factors on the self-administration of cocaine. Cocaine self-administration will be carefully monitored while their daily caloric intake is increased or decreased. The goal of the fourth study is to determine withdrawal signs and symptoms from cocaine abstinence. Measures will be taken during cocaine self-administration and subsequent removal of the drug. The results from these studies will lead to future animal and human studies which will examine other factors contributing to decreases in cocaine self- administration, withdrawal effects, and relapse to drug use.

Crack cocaine use continues to be a major public health problem with consequent legal, social and personal costs. In spite of this major concern over the use of smoked cocaine, limited human laboratory and systematic research has been conducted on examining pharmacological agents that may reduce cocaine self-administration or relapse. The development of human laboratory models of cocaine self-administration, relapse and withdrawal so that potentially effective pharmacological agents for the treatment of various aspects of cocaine abuse can be tested is very important. The use of these models will provide: (a) a better understanding of whether a particular drug affects the reinforcing effects from cocaine, may prevent relapse and/or affects withdrawal symptoms from cocaine, (b) a measure of the safety of the drug when used in conjunction with cocaine, (c) and a cost effective method for making these determinations. The primary purpose of the proposed studies are to test various medications using models of self-administration, relapse and acute withdrawal. The medications that we would like to test are ritanserin, a 5-HT2 antagonist, and nifedipine, a calcium ion channel inhibitor. These drugs were chosen because: (a) they have different mechanisms of action; (b) animal or human studies indicate that they may affect the reinforcing effects of cocaine; and (c) each appears to minimize the toxic effects of cocaine. In addition, ritanserin is attractive because of the potential specificity of its selective 5HT2 receptor blockade. Five studies are proposed. The purpose of the first experiment will be to determine the effects of escalating doses of ritanserin on cocaine self-administration. We hypothesize that increasing doses of ritanserin will result in greater decreases in the self-administration of cocaine. The second experiment will examine the effects of ritanserin on relapse to cocaine in the presence of cocaine- related and neutral stimuli. The hypothesized result is that subjects randomly assigned to the placebo condition will show a greater probability of and extent of self-administering cocaine in the presence of cocaine-related stimuli compared to those assigned in the ritanserin condition. The third experiment will examine the effects ritanserin on the disruptions due to acute withdrawal from cocaine. We hypothesize that the subtle signs of acute withdrawal observed in previous studies will be reduced with ritanserin. The fourth and fifth experiments and hypotheses will be the same as the first two except nifedipine will be the medication under investigation. The effects of nifedipine on acute cocaine withdrawal symptoms will be pursued in the future.

Cocaine use has become an increasing concern over the past several years. The use of smoked cocaine has increased from 1% in 1977 to 18% in 1984 due to low cost and rapid onset of effects. More recently the use of smoked cocaine has declined among recreational users, however, the use among those addicted to cocaine remains high. In spite of this concern over the use of smoked cocaine, few studies have examined the effects of smoked cocaine in humans. Furthermore, little systematic research has been conducted on pharmacological and behavioral factors which may affect different stages of smoked-cocaine use. In part, the paucity of research in this area reflects the difficulty of administering precise doses of smoked cocaine which is necessary in parametric studies. Our laboratory has developed a method of delivering precise doses of smoked cocaine in humans. Over the past two years during the previous grant period, we have conducted several studies which have examined the effects of multiple doses of smoked cocaine in both humans and animals and factors which affect the reinforcing properties of cocaine. There are two major human experiments proposed for the current grant application. The results from these experiments will provide human laboratory models of self-administration. The goal of the first experiment is to develop a model of self-administration which incorporates a work requirement or a motivational aspect of self-administration. Subjects will be required to work on a task to earn tokens, valued at a fixed amount ($3.00) or a varied amount ($1, $3 or $5), which can be exchanged for various doses of cocaine (.1, .2 or .4 mg/kg) or a fixed dose of cocaine (.2 mg/kg) respectively. This model will be compared with the current self-administration model we have developed which does not include a work requirement. The goal of the second experiment is to investigate the effects of sertraline, a serotonin re-uptake blocker, on the self- administration of smoked cocaine. Toxicity of sertraline when administered in conjunction with cocaine will be determined first. Then the effects of sertraline on both models of self-administration (with and without work requirement) will be examined.

The purpose of this Medication Development Research Center grant is to systematically and comprehensively test different potentially therapeutic drugs using human laboratory models of drug abuse for opiates, cocaine and cigarette smoking. This center grant will also examine how the results from human laboratory models will generalize to an outpatient clinical setting. Four individual projects and three Cores have been submitted. The first project focuses on the effects of dynorphin A (1- 13), an endogenous opiate, in opiate abusers. The proposed studies examine the effects of dynorphin on heroin withdrawal, the effects of dynorphin on the self-administration of opiates, the interaction of dynorphin and morphine in opiate-naive and opiate-dependent subjects, and the self-administration of dynorphin. The second project examines the effects of ritanserin, a 5-HT2 antagonist, and nifedipine, a calcium channel inhibitor, as potential pharmacological agents in the treatment of cocaine abusers. Studies will be conducted to determine the effects of these medications on human laboratory models of cocaine self- administration, relapse and withdrawal. The third project will examine the effects of ritanserin using an outpatient clinical setting in female cocaine abusers who do or do not have a current history of affective disorder. Studies will be conducted to examine the effects of ritanserin on cocaine self-administration and relapse to cocaine. The fourth project examines the role of a metabolite of nicotine, cotinine, in tobacco dependence. The proposed studies will examine the effects of cotinine during cigarette abstinence, physical dependence of cotinine, the self-administration of cotinine, and the effects of cotinine on cigarette smoking. The strengths of this application include 1) the testing of novel compounds as potential medications, 2) the use of parallel designs and methodologies across drugs, 3) the extension of laboratory findings to an outpatient setting, 4) the presence of ongoing clinical research programs and funded grants in these areas among the investigators, and 5) well established collaborations among the investigators, and 6) the integration of the proposed clinical studies with strong preclinical and basic research programs in drug abuse, and a drug abuse training grant, at the University of Minnesota. All four studies will use the services provided by the three proposed Administrative and Support, Analytical and Statistical Cores.

crack cocaine; inhalation drug abuse; model design /development; biological models; self medication; relapse /recurrence; behavioral /social science research tag; clinical research; human subject;

The purpose of this study is to determine the effects of phenytoin on smoked cocaine-base self-administration using our laboratory self- administration model. A total of 12 patients will be randomized, 6 to phenytoin and 6 to placebo treatment group. We predict that phenytoin in a dose dependent manner will decrease cocaine-self-administration.

Nicotine has been considered to be the primary drug that produces dependence on tobacco products. However, several studies that have been recently conducted show that metabolites of nicotine, particularly cotinine, may play a role in the complex dependence process. These studies have shown that cotinine administered to smokers during cigarette abstinence produces specific symptoms and may reduce tobacco withdrawal symptoms in a dose-related manner. The proposed studies attempt to elucidate the role of cotinine in tobacco dependence and its possible role for tobacco cessation. The studies will examine the effects of cotinine on tobacco withdrawal symptoms, physical dependence on cotinine, the self-administration of cotinine, and the effects of cotinine on the amount of tobacco use. More specifically, the first study will examine the effects of cotinine in comparison with the effects of the transdermal nicotine system (TNS), and a combination of both products during smoking withdrawal. The purpose of the second study will be similar to the first except the study will be undertaken on an outpatient basis. An outpatient study is essential since cues for smoking are different in the natural environment as opposed to an inpatient environment. For both the first two studies, the hypothesized result is that the administration of cotinine will show a different profile of effects than the nicotine transdermal system; cotinine will affect withdrawal symptoms differently than placebo; and the combination of cotinine and nicotine may either show an augmented or antagonistic effect. The third outpatient study will determine whether cotinine produces physical dependence. The potential symptoms of withdrawal from cotinine will be compared with those from cigarettes. The hypothesized result is that cotinine will lead to fewer withdrawal symptoms than from cigarette smoking and that cotinine withdrawal symptoms will be minimal. The fourth study will determine the self-administration of cotinine compared to placebo, and various doses of cotinine compared to each other during cigarette withdrawal. The hypothesized result is that cotinine will be chosen over placebo, and higher doses over lower doses. The purpose of the fifth study is to determine the effects of cotinine vs. placebo on the self- administration of cigarettes. The hypothesized result is that cotinine will reduce the self-administration of cigarettes, and higher doses will reduce cigarette smoking to a greater degree. These studies should provide a better understanding of how a metabolite may contribute to the dependence on a drug.

cocaine; human therapy evaluation; drug screening /evaluation; drug abuse chemotherapy; serotonin inhibitor; clinical research; human subject;

The purpose of this TTURC proposal is to examine tobacco exposure reduction methods to treat smokers who have been resistant to conventional methods of intervention or who have not been previously targeted. Reduction of tobacco use will be examined both as a potential transitional goal toward cessation, or as an endpoint for refractory smokers. The center grant proposal involves five research projects and three cores. The five projects vary from animal studies to human clinical trials. Dr. Paul Pentel will use animal models of nicotine self- administration to study the use of high dose nicotine (doses producing plasma nicotine concentrations exceeding those experienced by smokers) as a treatment strategy. The combined use of high dose nicotine and the antagonist mecamylamine, and the effects of high dose nicotine on tobacco carcinogen activation will also be evaluated. Dr. Dorothy Hatsukami will conduct short-term, tightly-controlled human behavioral pharmacology studies that examine different methods of reducing toxic exposure to tobacco. These methods include nicotine replacement products and behavioral methods to reduce the amount of cigarettes smoked. Drs. Larry An, Harry Lando and Anne Joseph will examine exposure reduction treatment methods in targeted populations unable or unwilling to become abstinent or who are on the trajectory towards nicotine dependence. The targeted populations to be examined will vary across the life span including mothers who smoke, adolescent experimental smokers and medically compromised smokers. Research on each population will have unique as well as common methods for assessment and treatment with the primary outcome measures being the reduction in tobacco use and toxicity, the degree to which these treatments facilitate abstinence, and the cost- effectiveness of these approaches. The Core facilities will include Biomarker, Administrative, and Design and Analysis Cores. Drs. Stephen Hecht and Sharon Murphy will be co-directors of the Biomarker Core. This Core will provide measurement of biomarkers for tobacco, nicotine and carcinogen exposure and the capability to phenotype individuals according to their metabolism of nicotine. The Design and Analysis Core will be responsible for data input, monitoring and statistical analyses and for performing the economic and policy analyses for each of the clinical studies. The Administrative Core will be responsible for the smooth and coordinated operation of the studies, the training and career development of students and faculty, and the dissemination of information. In summary, the goal of this highly interdisciplinary center grant is to systematically examine tobacco exposure reduction methods that will decrease mortality and morbidity associated with tobacco use.

sympathetic ganglion; hormones; drug abuse; adrenal medulla; stimulant /agonist; cocaine; nicotine; reinforcer; antiadrenergic agents; clinical research; human subject;

DESCRIPTION: (provided by applicant) Approximately 40-80 percent of adolescent daily smokers have tried to quit smoking, but have been unsuccessful. Present treatments for adolescent smokers have not produced high rates of tobacco abstinence. On the other hand, a significant number of young smokers who have failed to achieve abstinence have been able to reduce their levels of smoking. Few studies have examined the course of these outcomes and whether intervention focusing on reducing or sustaining reduced smoking among the adolescent who cannot quit would produce more effective long-term treatment results. The goal of this grant proposal is to determine whether treatment aimed at smoking reduction among adolescents unable to quit is a viable method of intervention. Two studies are proposed. The first study will determine effective methods for smoking reduction. Adolescents uninterested in quitting will be randomized to one of four conditions for a period of 4 weeks: 1) placebo medication, 2) nicotine patch, 3) nicotine gum, and 4) bupropion. Outcome measures will include compliance to the method of treatment and extent of smoking reduction. The second study will involve a tobacco exposure reduction intervention among those adolescents unable to quit smoking. All adolescents enrolled in the study will be provided smoking cessation treatment. Those adolescents who are unsuccessful will be randomly assigned to an intervention focusing on reduction of smoking or usual care. Those assigned to the reduced smoking intervention will be provided the treatment method(s) that are demonstrated to be efficacious in reducing smoking in the first study. The usual care group will be seen for the same frequency of treatment visits as the reduction group to control for clinic contacts. Follow-up will occur with all groups (successful abstainers and those randomly assigned to interventions) at 12, 26 and 52 weeks. The outcome measures will include a comparison between the reduction intervention group and the usual care on: (1) extent of cigarette reduction and percent who reduce by > 50 percent of baseline; (2) the percent of adolescent smokers who eventually become abstinent from smoking; and (3) the course of treatment outcome. We hypothesize that those individuals who are assigned to tobacco reduction treatment condition compared to the usual care condition will sustain a reduced level of smoking and experience greater eventual success in achieving abstinence.

A significant population of smokers is unable or unwilling to quit smoking. As a consequence, strategies to reduce toxin exposure are being considered as a potential means of reducing tobacco-related morbidity and mortality. The purpose of this research project will be to continue to systematically examine the amount of toxin exposure across various reduction strategies and potential reduced exposure products (PREPs) using short-term, well-controlled clinical trials. In our prior TTURC project, we have focused on determining reliable and dose-responsive surrogate biomarkers for tobacco toxin exposure and risk factors for disease, and how different PREPs affect these biomarkers and the achievement of abstinence. We will expand our research efforts to better understand the underlying mechanism associated with different approaches for exposure reduction and explore factors influencing individual differences in treatment response. The focus will be on PREPs that primarily manipulate nicotine dose and closely parallels the animal studies proposed in Project 2 (Nicotine Exposure Reduction in Rats) of this TTURC. The four proposed studies involve: 1) reducing nicotine by reducing the number of cigarettes smoked; 2) reducing nicotine by reducing the nicotine yield of the cigarette smoked vs. nicotine lozenge; 3) reducing nicotine by using an antagonist treatment, nicotine vaccine; and 4) increasing nicotine by using high dose of nicotine patch with or without nicotine-free cigarettes. Subjects will be assessed at baseline, during six weeks of treatment with these products, and then during six weeks of abstinence. The aims of the studies are to examine and compare the effects of these intervention approaches on: 1) biomarkers for tobacco toxin exposure and risk factors for disease; 2) extent of compensatory smoking, a strong determinant of toxin exposure; and 3) different aspects of tobacco addiction (e.g., physical dependence, negative affect, responses to cues, etc.). In addition, factors (genotype and phenotypes) that moderate the extent of exposure and that impact subsequent cessation will also be examined. This project, along with the TTURC projects, will provide important evidence-based data on alternative intervention methods that may potentially reduce mortality and morbidity associated with tobacco use.

CRISP; Computer Retrieval of Information on Scientific Projects Database; Drug Kinetics; Funding; Grant; Immunization, Booster; Immunization, Secondary; Infusion; Infusion procedures; Institution; Investigators; NIH; National Institutes of Health; National Institutes of Health (U.S.); Nicotine; Pharmacokinetics; Purpose; Pyridine, 3-(1-methyl-2-pyrrolidinyl)-, (S)-; Research; Research Personnel; Research Resources; Researchers; Resources; Secondary Immunization; Source; United States National Institutes of Health; Vaccinated; Vaccination; Vaccines; booster vaccination

This subproject is one of many research subprojects utilizing the resources provided by a Center grant funded by NIH/NCRR. The subproject and investigator (PI) may have received primary funding from another NIH source, and thus could be represented in other CRISP entries. The institution listed is for the Center, which is not necessarily the institution for the investigator. Objective: To compare nicotine pharmacokinetics and subjective effects of three newer smokeless tobacco potential reduced exposure products (PREPs;Ariva, Revel, Stonewall) to moist snuff (Copenhagen) and medicinal nicotine (Commit lozenge). Methods: Ten subjects completed a randomized, within-subject, cross-over study. Subjects used one product for 30 minutes at each of five laboratory sessions. Maximal nicotine concentration (Cmax) was determined and area under the concentration time curve (AUC) was calculated for a 90 minute period (during use and 60 minutes post-use). Nicotine craving, withdrawal symptoms and ratings of product effects and liking were measured during product use.

DESCRIPTION (provided by applicant): Oral non-combusted tobacco products have the greatest likelihood of leading to harm reduction compared to other potential reduced exposure products (Gray et al., 2005; Hatsukami & Hecht, 2005). Tobacco companies have been developing and marketing oral tobacco products that appeal to cigarette smokers as a substitute for cigarettes. Some public health researchers believe that switching smokers to oral tobacco would lead to a significant reduction in mortality and morbidity and point to data showing significantly less health risk with smokeless tobacco use compared to cigarette smoking. However, very little research has examined if smokers in the US will find oral tobacco products palatable as a cessation aid, the toxicity of these products compared to cigarettes as assessed by biomarkers of exposure and toxicity in humans, and whether or not use of these products will result in significant smoking cessation rates, particularly compared to FDA approved cessation products, such as medicinal nicotine. This proposal describes two studies which will be the first systematic effort to address these questions. The first study will determine the palatability and preference of various oral non-combusted tobacco products in cigarette smokers, which will inform the product to be tested in Study 2. Smokers will be presented with four brands of oral tobacco that are all low in tobacco specific nitrosamine levels but vary in nicotine content and product type. Subjects will sequentially, and in randomized order, sample each of these products and at the end of the sampling period, choose which product that they would like to use during a subsequent 4-week abstinence from smoking. The main outcome measure will be determining the product that is most preferred, which will then be used in the subsequent clinical trial. Other outcome measures include pattern of product use, subjective and physiological responses to the product, withdrawal symptoms from the product and biomarkers of exposure and toxicity. The second study will be a randomized clinical trial comparing the efficacy of an oral tobacco product compared to a medicinal nicotine product for smokers wishing to quit. Subjects will be randomized to either the most preferred oral tobacco product determined in Study 1 or nicotine gum for a period of 12 weeks. Follow-up will occur at 26 and 52 weeks. The primary outcome variables are abstinence rates across the two products, extent of cigarette reduction in non-abstainers and continued product use after the end of treatment. Other outcome variables are similar to the first study. A cost analysis will be conducted if the oral tobacco product is similar to or exceeds the cessation rates of medicinal nicotine. The results from these studies will help determine the effects and feasibility of using oral tobacco products as both a cessation aid and a method to reduce individual health risk in cigarette smokers.

DESCRIPTION (provided by applicant): Innovative strategies for tobacco cessation must be considered. Currently, there are 44 million smokers in the US and 1.2 billion smokers world-wide. Although 22 million smokers try to quit smoking each year, only 3-5% are successful in becoming sustained abstainers. Even with the best treatments which combine pharmacotherapy and behavioral treatment, on average long-term abstinence rates are around 25%. Furthermore, at any one time, only 4-20% of smokers are ready to quit smoking. Unless there is a dramatic change in the trends, by year 2025, it is anticipated that 10 million smokers will die per year world-wide from tobacco-caused diseases. Recent publications and discussions have focused on the tobacco product as target for reducing tobacco-related morbidity and mortality by either reducing toxicants and/or nicotine in the product or by altering the delivery system. These types of potential reduced exposure products (PREPs) have been increasingly surfacing in the U.S. market. A strategy to utilize these products in conjunction with existing pharmaceutical products may provide a novel method to help people who are unable to quit through traditional cessation methods or may improve on existing pharmacotherapies. Examining PREPs that primarily manipulate nicotine dose and speed of nicotine delivery would be particularly instructive in understanding potential treatment targets and methods that will enhance cessation success. To this end, this propose study will randomize cigarette smokers to: 1) Lower nitrosamines, high and rapid nicotine delivery oral tobacco products for 4 weeks and then nicotine patch alone for an additional 4 weeks;2) denicotinized cigarettes (which provides sensory behavioral aspects of smoking) plus nicotine patch for 4 weeks and nicotine patch alone for an additional 4 weeks;or 3) nicotine gum or lozenge plus nicotine patch for 4 weeks and then nicotine patch alone for 4 weeks, with the goal of abstinence. Outcome measures will include withdrawal symptoms and craving, time to lapse to usual brand of cigarettes, cessation assessed at the end of treatment and at 12 and 24 weeks post-treatment, and biomarkers of exposure and toxicity. Predictors of treatment response for each of the treatment conditions will also be explored. The results of this project should provide valuable information on innovative methods for reducing tobacco toxicant exposure and promoting cessation and a better understanding of the underlying mechanisms of and contributors to treatment response. Furthermore, the results from this study will provide guidance for future large, longer-term clinical trials to test promising interventions and will also provide guidance for policy directions. PUBLIC HEALTH RELEVANCE: This project will examine innovative strategies for cigarette smoking cessation. Currently marketed tobacco products that result in reduced tobacco toxicant exposure will be used in conjunction with medicinal nicotine to provide a novel method to help smokers quit smoking. These tobacco products will vary in level of nicotine dose and speed of nicotine delivery and smokers will graduate from these products to using solely medicinal nicotine products prior to complete cessation. The results of this study will provide useful information on directions to pursue to improve our pharmacotherapies and behavioral treatments and to better understand the various aspects of addiction.

Cancer Center Support Grant; Leadership; programs;

8.1.1 ABSTRACT: PREVENTION AND ETIOLOGY The Prevention &Etiology program, lead by Dorothy Hatsukami, Ph.D: and DeAnn Lazovich, Ph.D., has 51 members, representing 12 departments and six schools or colleges (Medical[unreadable]Twin Cities and Duluth, Public Health, Food, Agricultural and Natural Resources, Pharmacy, Nursing, Social Work). As of October 1, 2007, these members have a total of $28 million in Peer-reviewed, funded research projects for the current budget period. Since June 2003, their research has resulted in 667 publications, of which 27% were intraprogrammatic and 10% were inter-programmatic. The scientific goals of this program are to understand biological and behavioral factors in the etiology of cancer, reduce behaviors that may lead to cancer or enhance behaviors that decrease cancer risk, and improve the survivorship of cancer patients. To achieve these goals, we have strong research programs that fall into three primary themes: 1) cancer risk reduction, which examines environmental, behavioral and biological factors associated with etiology and the reduction of tobacco, obesity and physical inactivity;2) adult and pediatric cancer epidemiology, which explores molecular genetic, physiological, nutritional and environmental influences that increase or decrease the risk for cancers;and 3) cancer diagnosis, outcomes and survivorship, which explores the efficacy of cancer screening to reduce cancer mortality arid the consequences of cancer treatments and methods to improve cancer outcomes and quality of life. The Cancer Center has provided not only shared resources, but has funded 32 pilot projects, two research retreats, three monthly seminar meetings on tobacco, epidemiology, and cancer survivorship and outcomes, and a Prevention and Etiology newsletter to facilitate collaborations.

DESCRIPTION (provided by applicant): Currently, there are 7.7 million smokeless tobacco users in the U.S. Smokeless tobacco use has been associated with increased risk of oral pathologies (including oral cancer), pancreatic cancer, diabetes and other components of the metabolic syndrome, fetal toxicity and possibly cardiovascular disease. The extent of these health risks may be associated with the amount of toxicants in these products and the extent of exposure to these toxicants. Research has shown wide variability in carcinogens as well as nicotine in these products. The WHO Framework Convention on Tobacco Control and the proposed FDA legislative bill for tobacco product regulation have provisions that would require tobacco companies to reduce or eliminate harmful toxicants and to reduce levels of nicotine. However, very little research is available to guide decision makers on the impact of reducing toxicants and nicotine nor do we completely understand factors other than product toxicity that are associated with the extent of toxicant exposure. Two studies are proposed with the following goals: 1) Study 1 will examine brands of U.S. smokeless tobacco (ST) products that contain different levels of tobacco specific nitrosamines (TSNAs), other carcinogens and nicotine on existing and novel biomarkers of exposure and effect. In addition, this study will comprehensively determine factors that moderate the extent of exposure other than the levels of toxicants in these products. These factors include individual, social and environmental influences. Subjects will be recruited from 3 different regions in the U.S. and will be assessed on two different occasions. This study will contribute new information on critical factors associated with toxicant exposure. 2) Study 2 will determine the effects of switching ST users to lower TSNA and high, moderate or low nicotine ST products on pattern of use, biomarkers of exposure and toxicity, and facilitation of abstinence. Subjects will undergo measurements during use of their usual brand of smokeless tobacco and then switch to the assigned product for 12 weeks, with follow-up at week 13 and 26. This study would demonstrate the feasibility and impact of switching ST users to less toxic ST products. Together, these studies will help to guide important policy decisions to reduce the toll of tobacco-related disease.

Program Goals and Scope. Tobacco use is the foremost cause of premature death in the U.S. About 21% of adults are current smokers and smoking rates have not declined in recent years. Although available pharmacotherapies can aid in quitting smoking, quit rates vary substantially in subgroups of smokers. Thus, smoking is a significant clinical problem with a great need for research to improve treatment outcomes. The goal of the Pharmacogenetics of Nicotine Addiction Treatment (PNAT) research program is to generate the evidence base to optimize pharmacotherapeutic choices for individuals who wish to quit smoking. Building upon a strong foundation of translational pharmacogenetic (PGx) science conducted by this transdisciplinary team during the past 4 years. we propose in this competing renewal to: (a) conduct a multi-center prospective stratified PGx clinical trial to establish the predictive validity and cost-effectiveness of a genetically-informed biomarker to optimize smoking cessation treatment; (b) identify additional gene variants altering nicotine pharmacokinetics (PK), as well as pharmacodynamic (PD) gene variants influencing therapeutic response; and (c) elucidate causal mechanisms underlying associations of our PGx marker with smoking cessation.

"This contract is in support of activities conducted by the National Cancer Institute's DCCPS Tobacco Control Branch as part of the Tobacco Harm Reduction Network. "

Lung cancer is more prevalent in African Americans as compared to European Americans, and cigarette smoking is the major risk factor in both these groups. Tobacco-specific nitrosamines are among the most significant carcinogens in tobacco products. One ofthe most prevalent of these compounds, 4- (methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), is present in both unburned tobacco and cigarette smoke, and is a remarkably effective lung carcinogen in laboratory animals, inducing lung tumors in rodents independent ofthe route of administrafion. 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a metabolite of NNK, is also a pulmonary carcinogen, and its serum levels are related to lung cancer in smokers. Metabolism and DNA adduct formafion are crifical in cancer inducfion by NNK. Our goal is to understand whether the observed ethnic/racial differences in lung cancer incidence are due to variafions in NNK metabolism. Our overall hypothesis is that cancer susceptibility relates to carcinogen dose and to the balance between carcinogen metabolic acfivafion and detoxificafion. Our specific aims are: 1) Conduct a comprehensive analysis of urinary biomarkers of NNK metabolic acfivafion and detoxificafion in African American and European American smokers. This research builds on our recently developed methodology based on the use of deuterium-labeled NNK. 2) Measure in exfoliated oral mucosa cells of African American and European American smokers DNA adducts formed as a result of NNK metabolic activafion. This is crifical to an understanding of the balance between the urinary excrefion of NNK metabolites and the extent of NNK DNA binding. In the future, this balance could serve as a direct indicator of cancer suscepfibility in humans. 3) Investigate the relationship between levels of NNK-derived DNA adducts measured in oral mucosa cells and the rates of repair of these adducts in cultured lymphocytes from our subjects. This research will complement the results obtained in Specific Aims 1 and 2. In summary, the results of these experiments will provide excifing new data on differences in NNK metabolic activation and detoxification, as well as formation of NNK-derived DNA adducts and related DNA repair capacity in African Americans and European Americans. This will also help to test the overall hypothesis that differences in the mechanisms of NNK carcinogenesis are related to lung cancer susceptibility in humans.

The question driving this P50 application is Would an FDA-mandated new standard requiring very low nicotine levels (e.g., <0.20 mg) in cigarettes reduce cigarette use and improve public health? Addressing this question requires a coordinated effort in which different disciplinary approaches are integrated with the common goal of conducting high quality research and translating this research into evidence-based policy recommendations. The Administrative Core (Core A; Core Leaders: Eric Donny and Dorothy Hatsukami) will be housed at the University of Pittsburgh and will serve the following functions: 1) to provide management and oversight of the P50 and facilitate communication and collaboration among the investigators; 2) to develop and maintain integrated and quality methods, measures, data collection, and data management; 3) to provide forums for discussing how these studies contribute to the potential regulation of nicotine and other addictive constituents of tobacco; 4) to disseminate our findings to researchers, regulatory agencies and the public; and, 5) to fund pilot studies that address other research gaps in tobacco product evaluation. Committees formed under this Core will assist in performing these functions including a Steering Committee, a Conceptual Framework and Translational Science Committee, a Dissemination and Policy Committee, and a pilot Project Committee. Furthermore, an Internal and External Advisory Board will provide biannual and annual input respectively on the overall direction of the center, areas that need to be addressed, and progress being made. In summary, this Core will ensure communication and collaboration across investigators, the maintenance of high quality science and translation of the project results to have maximal impact on policy and public health.

This contract provides support services for the Tobacco Harm Reduction Network managed by the Tobacco Control Research Branch located within the NCI Division of Cancer Control and Population Sciences.

Innovative strategies for tobacco control must be considered. Currently, there are 44 million smokers in the US and 1.2 billion smokers world-wide. Unless there is a dramatic change in the trends, by year 2020, it is anticipated that 7 million smokers will die per year world-wide from tobacco-caused diseases. One approach that has the potential to have significant impact in reducing tobacco-related mortality and morbidity is reducing the nicotine content in cigarettes to levels that are non-addictive. Experimenters of cigarette smoking would have a reduced risk of becoming dependent and dependent smokers would have a greater chance to become smoke-free. Although this measure has been considered as technically feasible, many research gaps need to be addressed before considering nicotine reduction as a policy measure. The goals of this proposal is to address some of the key research gaps including: 1) the best strategy for nicotine reduction (immediate reduction to very low nicotine cigarettes versus gradual reduction in nicotine content of cigarettes), 2) effects of these strategies over time; and 3) identification of factors that may moderate responses to reduced nicotine content (RNC) cigarettes. Smokers will be randomized to three different experimental conditions: 1) very low nicotine content (VLNC) cigarettes with a 0.06 mg nicotine yield (actual dose to be determined by Project 2; N=200); 2) gradual reduction in nicotine content cigarettes (.8 mg, .6 mg, .4 mg, .2 mg and 0.06 mg yield cigarettes, each smoked for a period of 4 weeks, N=200); and 3) usual brand cigarettes as a control group (N=100). Over the 20-week experimental phase, subjects will be assessed for pattern of tobacco use, biomarkers of exposure and effect, subjective responses (e.g., satisfaction, craving withdrawal symptoms), cognitive performance and smoking topography. At the end of the experimental phase, they will be followed for another 4 weeks to assess abstinence from all tobacco products and smoking rate. The results from this study will describe the possible risks and benefits of two approaches for reducing nicotine in cigarettes and help inform future research in this area. This project will complement and use similar measures as Projects 2 and 3. RELEVANCE (See instmctions): The goals of this proposal is to address some of the key research gaps including: 1) the best strategy for nicotine reduction (immediate reduction to very low nicotine cigarettes versus gradual reduction in nicotine content of cigarettes), 2) effects of these strategies over time; and 3) identification of factors that may moderate responses to reduced nicotine content (RNC) cigarettes.

DESCRIPTION (provided by applicant): The overarching goal of this center application is to determine how marked reduction in the nicotine content of cigarettes impacts the use and effects of tobacco in current smokers. Reduction in nicotine content has been proposed as a potential regulatory measure to render cigarettes non-addictive and, consequently, to reduce smoke exposure and improve public health. Reducing nicotine content in cigarettes has become a possibility as a result of the passage of the Family Smoking Prevention and Tobacco Control Act (FSPTCA), which gives the Food and Drug Administration jurisdiction over tobacco products including the authority to reduce (but not ban) levels of nicotine in cigarettes. The proposed grant with its four inter-related projects, which cross disciplinary boundaries, will help to inform policy decisions. Project 1 includes two human studies evaluating the dose-response relationship for nicotine yield within the range thought to be at or below threshold for dependence and the potential use of concurrent nicotine replacement therapy (NRT) to facilitate the transition to VLNC cigarettes. Project 2 is a multi-site trial assessing the effects of prolonged use of VLNC in a large sample and comparing immediately switching to VLNC cigarettes to gradually reducing the nicotine content in cigarettes over a period of 20 weeks. Project 3 begins to address an important concern about the viability of a new standard for nicotine content in sub-populations (here we focus on smokers with schizophrenia) who might be particularly vulnerable to the effects of reduction in nicotine. Project 4 addresses concerns that the manipulation of other constituents in tobacco could offset the predicted gains of VLNC cigarettes by determining the relationship between the threshold dose for maintaining rat nicotine self-administration and the presence of minor alkaloids, beta-carbolines, acetaldehyde, and MAO inhibitors. The contribution of this Project to the overall center is Crucial. To accomplish these goals, we have proposed an Administrative Core (Core A), a Biomarkers Core (Core B), and a Biostatistics Core (Core C).

Global Tobacco Control and Prevention Network

8.1.1 ABSTRACT: PREVENTION AND ETIOLOGY The Prevention & Etiology program, lead by Dorothy Hatsukami, Ph.D: and DeAnn Lazovich, Ph.D., has 51 members, representing 12 departments and six schools or colleges (Medical¿Twin Cities and Duluth, Public Health, Food, Agricultural and Natural Resources, Pharmacy, Nursing, Social Work). As of October 1, 2007, these members have a total of $28 million in Peer-reviewed, funded research projects for the current budget period. Since June 2003, their research has resulted in 667 publications, of which 27% were intraprogrammatic and 10% were inter-programmatic. The scientific goals of this program are to understand biological and behavioral factors in the etiology of cancer, reduce behaviors that may lead to cancer or enhance behaviors that decrease cancer risk, and improve the survivorship of cancer patients. To achieve these goals, we have strong research programs that fall into three primary themes: 1) cancer risk reduction, which examines environmental, behavioral and biological factors associated with etiology and the reduction of tobacco, obesity and physical inactivity; 2) adult and pediatric cancer epidemiology, which explores molecular genetic, physiological, nutritional and environmental influences that increase or decrease the risk for cancers; and 3) cancer diagnosis, outcomes and survivorship, which explores the efficacy of cancer screening to reduce cancer mortality arid the consequences of cancer treatments and methods to improve cancer outcomes and quality of life. The Cancer Center has provided not only shared resources, but has funded 32 pilot projects, two research retreats, three monthly seminar meetings on tobacco, epidemiology, and cancer survivorship and outcomes, and a Prevention and Etiology newsletter to facilitate collaborations.

The Administrative Core will serve four functions: 1) to provide management and oversight of the P01 and facilitate communication and collaboration among the investigators; 2) to provide a mechanism for discussing how the methods, measures and results from our studies are interrelated and contribute to the testing of a conceptual framework for tobacco product evaluation that was developed under a contract from the National Cancer Institute (NCI); 3) to disseminate our findings to researchers, regulatory agencies and the public; and 4) to fund pilot studies that address other research gaps in tobacco product evaluation. To achieve these goals Drs. Dorothy Hatsukami and Peter Shields and an administrative team will oversee the management and smooth operation of the P01. The Steering Committee (chaired by Drs. Hatsukami and Shields), comprised of the Core Directors and Project Leaders, will be responsible for ensuring communication, collaboration and integration of the Projects. This Committee will also monitor the progress and productivity of the Projects. The Scientific and Policy Scientific Advisory Committee (chaired by Mitch Zeller) will assist in monitoring the progress of our studies, maintaining quality control over our science and ensuring our science will have a significant and positive impact on public health. The Tobacco Product Evaluation Committee (chaired by Drs. Peter Shields and Michael Cummings) will be responsible for guiding the integration of the results from our Projects, translating our science into policies and testing the conceptual framework for tobacco product evaluation. The Communications and Dissemination Committee will assist in determining the best methods to disseminate the results from our Projects and the content of the information that will be disseminated in order to have the most significant public health impact. The Pilot Project Committee will be responsible for soliciting, reviewing and funding pilot studies. The infrastructure provided by this Core will ensure optimal collaboration, project integration, and quality and impact of our results.

PROJECT SUMMARY (See instructions): The passage of the Family Smoking Prevention and Tobacco Control Act in June 2009 empowers the Food and Drug Administration to regulate tobacco products. In the FSPTC, there is significant focus on tobacco products and its evaluation. One critical component of this product evaluation process is human clinical trials. These trials will inform the regulatory agency about the uptake of the product, how the product is used, the extent of toxicant exposure and possible health risk associated with this pattern of use. To date, no study has examined the best experimental methods to provide the information that is necessary to make a sound scientifically-based decision about a tobacco product (e.g., modified risk tobacco products) or any regulations imposed on tobacco products (e.g., performance standards) that assures no public harm will result based on this decision. The goals of this research project are to test a clinical trial method for assessing tobacco products and also address some methodological gaps so that guidance can be provided to the FDA and other international regulatory agencies on the best measures and methods for the evaluation of tobacco products. This trial is a between-subject, parallel-arm design in which subjects are randomized to one of the five experimental conditions, with different instructional sets, for a period of 12-weeks. The product chosen for testing is an oral tobacco product. Camel Snus. The instructional sets include: complete substitution vs. partial substitution for cigarettes by ad libitum use vs. specific instruction for snus use. A control group of continuing smokers will also be included in the design. The primary outcome measures include biomarkers of toxicant exposure and effect and subjective responses to the product. The overall goal for this P01 is to assimilate the results from this Project with the results from the other P01 Projects to determine consistency of findings across studies, predicitive validity of measures, and to determine if the proposed

DESCRIPTION (provided by applicant): Lung cancer is the leading cause of cancer death in the United States and worldwide. Cigarette smoking causes approximately 90% of lung cancer. Despite anti-smoking campaigns over the past 40 years, over 45 million (22%) adult Americans are still current smokers. The development of a viable chemoprevention strategy targeting current smokers potentially could decrease lung cancer mortality. Previous studies have shown (1) that the tobacco specific nitrosamine 4-(methylnitrosamino)-1-(3- pyridyl)-1-butanone (NNK) is a major lung carcinogen in tobacco smoke, (2) that 2-phenethyl isothiocyanate (PEITC) is a potent inhibitor of NNK-induced lung carcinogenesis in rats and mice, (3) that the mechanism of this chemopreventive effect in rats is inhibition by PEITC of NNK's metabolic activation by a-hydroxylation in the lung leading to significantly increased urinary levels of the NNK metabolites 4-(methylnitrosamino)-1-(3- pyridyl)-1-butanol (NNAL) and its glucuronides (NNAL-Glucs). Furthermore, in smokers, consumption of watercress, a rich source of PEITC, increased urinary excretion of NNAL plus NNAL-Glucs, a marker of NNK detoxification, by 33%, consistent with the results of the animal studies. Observational epidemiological studies have demonstrated that dietary intake of cruciferous vegetables or isothiocyanates is associated with a reduced risk of lung cancer. The protective effect is confined to individuals with glutathione S-transferase (GST) M1 null-null or GSTT1 null-null genotype, and is particularly evident among those with the null genotypes of both GSTM1 and GSTT1. No protective effect was found among subjects with GSTM1-positive or GSTT1-positive genotype. The ultimate goal of our proposed research is to gain a full understanding of the mechanisms underlying the inhibitory effect of isothiocyanates on lung carcinogenesis in humans. The primary aim of this proposal is to assess, via a placebo-controlled cross-over design, the effect of PEITC supplementation (at 40 mg per day for one week) on changes of NNK metabolism in 80 smokers, who possess both the GSTM1 null- null and the GSTT1 null-null genotypes. We hypothesize that there will be a 30% increase in urinary NNAL plus NNAL-Gluc, and a similar magnitude of reduction in urinary hydroxy acid and keto acid, a-hydroxylation metabolites of NNK, among PEITC treated subjects. The secondary aims of the proposed study are to (1) examine the differential effect of PEITC supplementation on NNK metabolism and PEITC excretion between the null and non-null GSTM1/GSTT1 genotypes, and (2) to assess the effect PEITC supplementation (at 40 mg/day for 12 months) on reduction of cell proliferation (Ki-67) and induction of apoptosis (caspase-3 and TUNEL) in bronchial epithelia of current smokers. This is the first randomized intervention trial to assess the chemopreventive effect of PEITC on lung cancer development in humans. PUBLIC HEALTH RELEVANCE: Despite anti-smoking campaigns over the past 40 years, approximately 45 million adult Americans are currently smoking cigarettes and other tobacco products. Smoking-related lung cancer is the leading cause of cancer death in the United States and worldwide. The proposed study is to examine the effect of a dietary compound, 2-phenethyl isothiocyanate, on lung cancer protection in smokers. Supportive findings of this study will lead to the development of this compound as a dietary supplement for the protection against lung cancer development in smokers. The major strengths include the need for a randomized, placebo-controlled trial of PEITC, the qualification of the investigators, and the feasibility of the proposed studies.

DESCRIPTION (provided by applicant): In 2009, Congress enacted the Family Smoking Prevention and Tobacco Control Act (FSPTCA) which gave the Food and Drug Administration (FDA) regulatory authority over tobacco products. Under this law the FDA is required to evaluate new and modified tobacco products for their effects on a population wide-basis. Yet, there is limited knowledge on the measures and methods that should be used to evaluate these products. What is needed now are reliable and valid measures and methods that regulators can use to predict in advance how consumers are likely to respond (i.e., use leading to exposure) to new and modified tobacco products. This P01 builds on our previous NCI contract [N01PC644202], which proposed a comprehensive framework for evaluating tobacco products. This P01 attempts to test elements of that framework by conducting a series of interrelated studies designed to assess the potential uptake and dependence of a new oral tobacco product and resulting toxicant exposure in current cigarette smokers. To date, no systematic and comprehensive studies have been conducted to validate methods and measures for tobacco product evaluation. Specifically, Projects 1 and 2 will evaluate methods and measures to assess the relative abuse liability of tobacco products in animals and in humans. Project 3 seeks to understand and assess various aspects of consumer perception of tobacco products, and Project 4 assesses tobacco product use and its effects on exposure to toxicants in the context of a clinical trial. In addition to these Projects, we have an Administrative Core (Core A ) responsible for supporting the administration of the grant, facilitating collaboration, assuring the quality and timeliness of our science, integrating the results from the Projects and translating our research findings into potential policies; a Tobacco Constituent and Biomarker Core (Core B) that will be responsible for providing constituent analysis and analyzing our samples for carcinogen biomarkers of exposure and effect, and establishing a biorepository; a Biostatistics and Informatics Core (Core C) responsible for database development and management, statistical analysis for each of the projects, and coordinating data analysis across projects. At the conclusion of this P01 we will have produced evidence on the reliability and validity of an array of methods and measures that can be applied to predict how consumers are likely to use and abuse new and modified tobacco products. The findings from this study should directly influence the kinds of methods and measures that FDA and other regulatory groups around the world might apply to evaluating harm reduction potential of new and modified tobacco products. Furthermore, because of the integrative nature of the studies, this P01 will help us understand how product characteristics, product abuse liability and consumer perception of a product and moderating influences (i.e., sex, age, race/ethnicity) affects uptake and use and resulting toxicant exposure.

ABSTRACT The Clinical and Biomarkers Core is critical for the studies in this program project renewal proposal. The Core will recruit smokers to collect biological samples and will carry out analyses of tobacco constituent biomarkers. The biological samples collected by the Core will be used to evaluate and compare biomarkers of tobacco exposure across Japanese Americans, Whites, and Native Hawaiians in Projects 2, 3, and 4. Biomarkers to be analyzed by the Core include total nicotine equivalents (nicotine intake), 4-(methylnitrosamino)-1-(3-pyridyl)-1- butanol (NNAL) and its N- and O-glucuronides (exposure to tobacco-specific lung carcinogen NNK), phenanthrene tetraol and 3-hydroxy phenanthrene (exposure to and metabolism of the representative polycyclic aromatic hydrocarbon phenanthrene), mercapturic acids (exposure to acrolein, crotonaldehyde, and propylene oxide), urinary cadmium, as well as urinary biomarkers and DNA adducts derived from oxidative stress and inflammation. The measurements will be carried out on samples from a total of 6,084 subjects, with some of these samples being analyzed for only a subset of biomarkers. The samples from these subjects will either be procured from the existing bioresposity of the Multiethnic Cohort or obtained from smokers who are recruited by this Core. All assays, except for urinary cadmium, are based on stable-isotope dilution mass spectrometry and all have been analytically validated with respect to accuracy and precision. Personnel in this Core have extensive experience in clinical trials and quantitation of urinary tobacco biomarkers and DNA adducts, and were the first to develop many of the methods that will be used in this program project grant. The biological samples and biomarker results generated by this Core will be used by all projects.

PROJECT SUMMARY/ABSTRACT In the United States, there are 44 million smokers and about 500,000 tobacco related deaths yearly. The 2014 Surgeon General's Report stated, ? The burden of death and disease from tobacco use in the United States is overwhelmingly caused by cigarettes and other combusted tobacco products; rapid elimination of their use will dramatically reduce this burden.? Although comprehensive tobacco control measures have had a significant impact in reducing smoking, because nearly 1 out 5 Americans still smoke, novel tobacco control approaches to reduce combusted tobacco product use are needed. One of the most powerful tools granted to the Food and Drug Administration through the 2009 Family Smoking Prevention and Tobacco Control Act is the authority to establish product standards, which includes standards for nicotine to render the cigarette minimally addictive. This regulatory policy could have a profound impact on public health by minimizing the transition from experimental cigarette use to dependence, facilitating quit attempts, and reducing the occurrence of relapse. To date, studies conducted examining the effects of reducing nicotine to very low levels (e.g., 0.4 mg/g nicotine) are promising and show a reduction in smoking and dependence relative to normal nicotine content cigarettes and an increase in quit attempts. However, the majority of these studies, although strong experimentally, were not conducted in the context of a complex marketplace and as such the results from these studies may not adequately represent the full public health impact of reducing nicotine in cigarettes. For example, these studies provided study cigarettes at no cost, discouraged the use of other tobacco or nicotine products, blinded smokers to the dose of nicotine and had restrictive inclusion criteria. Project 1 will circumvent these limitations, simulating the ?real world? environment by providing participants access to an experimental marketplace where they will be given vouchers that can be exchanged for study cigarettes (varying in nicotine content) and non-combusted tobacco/nicotine products or cash, by informing participants about the nicotine content in cigarettes, and by broadening the criteria for study inclusion. More specifically, subjects (N=350 in each group) will be randomly assigned to: 1) very low nicotine content cigarettes (VLNC; 0.4 mg/g) along with non-combusted tobacco/nicotine products or 2) normal nicotine content cigarettes (NNC; 15.8 mg/g) along with non- combusted tobacco/nicotine products. We hypothesize that the VLNC cigarette condition will lead to: 1) greater use of non-combusted products; 2) fewer cigarettes smoked; 3) less exposure to tobacco- related toxicants; and 4) greater number of days of cigarette abstinence. We also hypothesize that VLNC will be associated with less positive effects than NNC, and greater positive effects of alternative non-combusted products than in the NNC condition. Finally, we hypothesize that specific groups of smokers will be more likely to seek and use non-combusted products (e.g., male, more dependent on cigarettes). This project will complement Projects 2 and 3 by examining, in a naturalistic rather than mechanistic fashion, the type of alternative product characteristics sought by smokers randomized to VLNC and NNC cigarettes and subject characteristics that might influence use of and responses to a multiple tobacco product marketplace.

ABSTRACT The Administrative Core (Core A) has four aims: 1) to provide management, integration and oversight of the P01 activities, facilitate communication and collaboration among the investigators, distribute research cigarettes to all projects and the Biomarker and Tobacco Constituents Core, and to establish a Data Safety and Monitoring Board (DSMB) to monitor participant safety. This aim will be facilitated by Drs. Dorothy Hatsukami and Peter Shields, the administrative team and the Steering Committee comprised of Project and Core Leaders; 2) to establish a Tobacco Product Evaluation Committee (TPEC), chaired by Dr. Shields and Mr. Micah Berman, that will provide a mechanism for discussing how the results from our studies are interrelated and contribute to the understanding of the potential public health impact of banning ventilation in cigarette filters; 3) to establish and manage a Scientific and Policy Advisory Committee (SPAC), chaired by Dr. Jonathan Samet, to provide a mechanism for the evaluation of our scientific productivity, significance and quality, and a resource for addressing unanticipated issues; and, 4) to establish and manage a Communications and Dissemination Committee (CDC), chaired by Drs. Richard O'Connor and Hatsukami, that will disseminate our findings to researchers, regulatory agencies and the public. The infrastructure provided by this Core will ensure optimal collaboration, project integration, and quality and impact of our results.

ABSTRACT The 2014 Surgeon General Report (SGR) concluded that there has been an unanticipated increase in lung adenocarcinomas, now the most common type of lung cancer. The SGR identified ventilation in cigarette filters, a design introduced in the 1960s and an important way to lower machine measured cigarette tar yields, as a potential contributor to the increase in these lung cancers. In a recent review, we found highly suggestive evidence that filter ventilated cigarettes was the cause of the increased incidence of adenocarcinoma lung cancer and concluded that there was enough evidence for the FDA to consider regulating filter ventilation, including a ban. Independent of the risk for adenocarcinoma, there would be sufficient justification for regulation based on the impact of ventilation on harmful constituent yields, smoking behavior and smokers' misperception of health risks. However, prior to any regulatory action, the consequences of such a ban needs to be studied. This P01 describes a set of systematic and comprehensive studies that examines the toxicity, appeal and abuse liability of unventilated filters as compared to ventilated filters in the context of a marketplace with and without alternative nicotine delivery systems (ANDS). Four integrated projects and three cores are proposed and involve a team of multi-disciplinary investigators who have worked together in developing validated models and measures to test tobacco products. The four projects address 1) how unventilated vs. ventilated cigarettes are smoked and the resulting carcinogen exposure levels and potential harm when used with and without ANDS (Project 1); 2) the relative abuse liability of these ventilated vs. unventilated cigarettes and the extent to which ANDS serves as a substitute for unventilated cigarettes (Projects 2 and 3); and 3) the effects of ventilation and product packaging/messaging on consumer perceptions of harm, response and uptake and how these perceptions can be modified by ANDS (Project 4). This research is novel in many ways, including the first to assess the impact of removing filter ventilation and doing this in the context of a complex tobacco marketplace. The projects that we propose are highly integrated. None of these studies alone can address the population impact of a ban on ventilation. It is the combination of these complementary studies that can address the impact of a ban on toxicity, uptake and intensity of product use to determine population health impact. The results of this study would provide critical information to the U.S. Food and Drug Administration on whether or not a ban would lead to improved public health.

PROJECT SUMMARY The toxic and carcinogenic exposures associated with e-cigarette use, and the potential long-term health outcomes are not well characterized. While the levels of most tobacco-related harmful constituents are generally much lower in e-cigarettes than in cigarette smoke, and the limited literature on biomarker-based human exposures generally supports these findings, the number of chemical constituents identified in e- cigarette aerosol continues to grow. Many of these newly identified constituents can potentially cause oxidative stress and inflammation, and result in DNA damage ? effects that are strongly implicated in the etiology of chronic diseases, including cancer and cardiovascular disease. In addition, our recent data indicate that the potent oral and esophageal carcinogen N?-nitrosonornicotine (NNN), which is present only in trace levels in e- cigarettes, can be formed in saliva of e-cigarette users. Better characterization of toxic and carcinogenic exposures and related effects in e-cigarette users will help to assess the potential long-term health effects of e- cigarette use. In this study, we will recruit smokers of regular cigarettes and will randomized to the following experimental conditions for 8 weeks: 1) complete switching from smoking to the Standard Research E- cigarette (SREC) developed by the National Institute of Drug Abuse (N=50); 2) complete switching from smoking to an oral medicinal nicotine product, such as nicotine gum or lozenge (N=50); and 3) continued smoking of usual brand cigarettes as a control group (N=25). Study participants will be assessed at baseline and weeks 1, 2, 4, 6, and 8 for smoking abstinence, SREC use patterns, topography, and subjective measures. We will incentivize participants assigned to SREC and medicinal nicotine to encourage complete abstinence from smoking. Biomarkers of exposure and effect will be assessed at baseline and weeks 4 and 8. Our specific aims are: (1) To analyze a panel of exposure biomarkers in smokers assigned to SREC and compare the exposure profiles against medicinal nicotine products and usual brand cigarettes. The biomarkers will include TNE, NNAL, PheT, and mercapturic acids HMPMA, 2-HPMA, and 3-HPMA. (2) To compare formaldehyde-DNA adducts in oral cells, 8-oxo-dG in DNA from leukocytes, a comprehensive panel of circulating cytokines and chemokines, and the urinary biomarkers of oxidative damage and inflammation 8-iso- PGF-2? and PGEM across the groups. (3) To analyze salivary NNN and oral cell HPB-releasing DNA adducts in smokers who completely switch to SREC and compare those who switch to medicinal nicotine products or continue smoking usual brand cigarettes. Collectively, the results of this study will provide important data on chemical exposures and associated effects in smokers switching to SREC, contributing to better understanding of the long-term health effects that may be associated with e-cigarette use.

ABSTRACT The 2014 Surgeon General's report indicated that there was suggestive evidence demonstrating that ventilated filters have played a role in the increased incidence of lung adenocarcinoma. In a more recent weight of evidence review by us, including an in-depth analysis of biological plausibility, we concluded that there was highly suggestive evidence that filter ventilation paradoxically increased the risk of lung adenocarcinoma, while other lung cancers decreased with decreasing smoking prevalence. This increase in risk is based on how ventilation alters the way the cigarette burns and the elasticity of the cigarette that allows greater delivery of nicotine and harmful smoke constituents to the peripheral parts of the lung, where adenocarcinomas more commonly occur. A strong case can be made for the FDA to consider regulating filter ventilation, including a ban, based on the increasing incidence of adenocarcinoma, enhanced toxicant exposures, misperceptions about the relative safety of these cigarettes and increased abuse liability resulting from the cigarette's elasticity. However, to date, there are no studies on the impact of removing filter ventilation on smoking behavior and resultant exposures and toxicity. Therefore, the primary goal of this project is to assess this, and importantly to do so in the context of an experimental marketplace that allows and does not allow access to alternative nicotine delivery systems (ANDS; e.g., e-cigarettes, smokeless tobacco and nicotine replacement therapy). Secondary aims include studying the predictors of exposure and the type and characteristics of ANDS that are chosen. The study design is a 2 x 2, in which smokers will be randomized (N=125 in each of 4 conditions and 20% dropout rate for final N=400) to ventilated or unventilated cigarettes, with and without access to ANDS. Both validated exposure and novel biomarkers (e.g., metabolomics and gene expression) collected in urine, blood, and lung will be analyzed during the course of the study. Smoking behavior will be assessed by puff topography and inhalation. We hypothesize that subjects using unventilated cigarettes will experience: 1) fewer cigarettes smoked; 2) less toxicant exposure and effect; 3) less smoking intensity and depth of inhalation; and 4) greater number of days abstinent from cigarettes, with greater effects observed among those smokers with access to ANDS. Furthermore, the predictors of cigarette use and exposure biomarkers will be dependent on cigarette type, access to ANDS, consumer perceptions and response to the cigarettes, demographic and smoking history variables. The type of product chosen will likely be e-cigarettes with higher nicotine doses and that are flavored. This project is innovative because it is the first to explore the effects of unventilated vs. ventilated cigarettes on a broad range of biomarkers, including ones that target the lung specifically, and within the context of a marketplace with ANDS. It is significant because it will provide the FDA information on whether or not there might be any unintended consequences if cigarette filter ventilation was eliminated.

ABSTRACT Not Applicable

Clinical Trial of Watercress in Detoxification of Environmental Toxicants and Carcinogens Summary In a recently completed clinical trial, we observed that 2-phenethyl isothiocyanate (PEITC) enhanced the detoxification of the environmental toxicants and carcinogens benzene, acrolein, and crotonaldehyde, as determined by increased excretion of the corresponding mercapturic acids in the urine of subjects who took 40 mg of PEITC orally per day. The significant enhancing effect was particularly strong in individuals who were null for the glutathione-S-transferase genes GST-T1, GST-M1, or both. These exciting results, which signal enhanced detoxification of commonly occurring environmental agents in subjects exposed to PEITC, led to the design of the current clinical trial of watercress, a common vegetable which is an abundant and practically unique natural dietary source of PEITC. When watercress is chewed or otherwise macerated, PEITC is released from its parent constituent gluconasturtiin. Thus, consumption of 10 grams wet weight of watercress exposes one to about 3 mg of PEITC. We hypothesize that watercress can enhance the detoxification of multiple environmental toxicants and carcinogens, thus emerging as an inexpensive and plentiful dietary constituent with potential for prevention of cancer and possibly other environmentally linked diseases. Therefore, we propose a clinical study of watercress with the following specific aims: 1. Prepare and standardize a watercress-derived beverage or capsules and appropriate placebo for the study. Two approaches will be investigated. A). Freeze-dry the watercress to obtain a powder which will be added to a mixture of fruit juices to mask the bitter watercress flavor. Subjects will drink this juice 10 min after mixing. B). Homogenize the watercress followed by freeze drying to produce a PEITC-containing powder which will be formulated into capsules. 2. Perform a clinical trial with 350 subjects to determine the effects of the watercress preparation on detoxification of environmental toxicants and carcinogens. Using a crossover design, subjects will consume the watercress beverage or capsules, or placebo, 3 times per day for 2 weeks with a 4 week washout period between watercress and placebo treatment. The target dose will be 40 mg/day of PEITC, as in our previous study. Urine, oral cells, saliva, and blood will be collected. 3. Using liquid chromatography-tandem mass spectrometry, analyze urine samples for mercapturic acids of specific toxicants (e.g. benzene, acrolein, crotonaldehyde, propylene oxide, etc.) and for mercapturic acids generally. Our hypothesis is that detoxification of these toxicants by conjugation with glutathione, as indicated by mercapturic acid levels in urine and DNA adduct levels in oral cells, will be significantly elevated compared to placebo in subjects who consumed the watercress preparation and are null for GSTM1, GSTT1, or both. The results of this study will provide a critical test of the use of watercress as a vehicle for isothiocyanates such as PEITC which can enhance detoxification of environmental toxicants and carcinogens. If the results of the trial support our hypothesis, watercress could emerge as a cheap and convenient food for cancer prevention, consistent with the concepts of ?green chemoprevention and frugal medicine.?

PROJECT SUMMARY Sugars, which are present naturally in some tobacco types and are also added to cigarette tobacco filler as additives, are not included in the FDA list of harmful and potentially harmful constituents (HPHC). Existing research data suggests that sugars in tobacco filler may contribute to the harmful properties of cigarettes in three critical ways: by enhancing smoke palatability and appeal and, as precursors to aldehydes and furans in the smoke, by increasing smoke toxicity and carcinogenicity and potentially addictiveness. Therefore, sugars are potentially the most versatile key constituents contributing to the smoking-associated morbidity and mortality. However, there is lack of robust quantitative data on the relationship between tobacco sugar content and relevant toxicant yields in U.S. commercial cigarettes, and the associated user exposures, behaviors, and cigarette appeal. In this study, we will leverage our combined expertise in tobacco chemistry, epidemiology, and human trials assessing biomarkers and behavioral and subjective measures, to address these key knowledge gaps. In Aim 1, we will use stable isotope-labeled sugars added to a commercial cigarette that is low in sugars and will analyze the dose-dependent formation of correspondingly labeled pyrolysis products in the smoke of this cigarette. to characterize the impact of sugars in the filler of U.S. cigarettes on the relevant chemical profile of cigarette smoke. We will also analyze the impact of sugar content on the levels of nicotine and tobacco-specific nitrosamines (TSNA) in the smoke. In Aim 2, we will analyze sugars in U.S. commercial cigarettes and use PATH biomarker data to investigate the impact of sugar content in cigarette tobacco on toxicant and carcinogen intake in U.S. smokers. In Aim 3, we will investigate the impact of sugar content in cigarette tobacco on cigarette abuse liability and appeal by conducting a laboratory study in which smokers will assess study cigarettes with differing levels of sugars in a laboratory setting. The overall goal of this proposal is to provide the FDA with the scientific basis to determine whether sugars should be added to HPHC list and whether their levels in tobacco products should be regulated.

Project Summary/Abstract The R25 Summer Research Program in PharmacoNeuroImmunology (PNI) provides 6 underrepresented undergraduate students of diversity each year an intensive laboratory-based research experience to increase their participation in biomedical graduate research programs. The R25 PNI program is a successful summer program which has trained 16 undergraduate students of diversity to date (additional 6 coming in the summer of 2020). The summer research program stems from our well-established NIDA-funded T32 PNI training program, which will provide engaged expert faculty mentors and a community of pre- and post-doctoral trainees to actively train and mentor the summer students supporting the mission of the PNI summer program. There is a well- recognized need to train biomedical scientists in an interdisciplinary and translational field that focuses on the interactions of drugs of abuse with the nervous and immune systems, and integrates our understanding of these physiological interactions with their behavioral counterparts. We will accomplish this by offering an intensive 10- week research experience that will provide qualified undergraduate students of diversity the necessary academic and research skills to ensure their competitiveness toward entering the next phases of their career - i.e., doctoral programs or medical school. The PNI summer program is part of the comprehensive Life Science Undergraduate Research Program (LSSURP) at the University of Minnesota. The PNI summer program is composed of an intensive laboratory-based research experience that entails close interaction with and mentorship by a program faculty member (n=31) that focuses on drug abuse research. This laboratory work is supplemented by a comprehensive educational curriculum, which includes seminars by program faculty on topics in biomedical research, ethics, and laboratory safety, and a focused student research poster symposium. An innovative component of our PNI program proposal is to deliver education modules with small group discussion. In addition, Dr. Jesse L. Mason, an alumnus of LSSURP and the T32 PNI training program, will provide a series of sessions for PNI summer students targeted toward dealing with adversity as a diverse student. To support the goal of the R25 Summer program, we propose two specific aims: 1) To provide an interdisciplinary structured research experience in the area of PNI, especially as it pertains to drug abuse; and 2) To provide skill sets for graduate careers in biomedical sciences. Those successful individuals will, in turn, act as role models for future students interested in research careers. Three measures of evaluation will be collected on a yearly basis: 1) Assessment of the 10 week summer research experience by participating undergraduate students and faculty in the program. This assessment will come in two ways from the LSSURP survey and a PNI specific survey; 2) The PNI program itself will be supported by the Advisory Committee to verify that we are meeting the goals of the program in diversity recruitment and effective research experience; and 3) Outcome assessment of the students that were in the program. We will track the careers in biomedical sciences of the past summer PNI trainees.