Scientific Methods to Evaluate Potential Reduced-Risk Tobacco Products

SCIENTIFIC METHODS TO EVALUATE POTENTIAL REDUCED-RISK TOBACCO PRODUCTS

LSRO

Life Sciences Research Office 9650 Rockville Pike Bethesda, Maryland 20814 www.LSRO.org

Catherine L. St. Hilaire, Ph.D. Editor

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Copies of the publication may be obtained from the Life Sciences Research Office. Orders and inquiries may be directed to: LSRO, 9650 Rockville Pike, Bethesda, MD 20814-3998. Tel: 301-634-7030; Fax 301-634-7876; web site: www.LSRO.org

ISBN: 0-9753167-7-X Library of Congress Catalog Number: 2007921706

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. FOREWORD The Life Sciences Research Office, Inc. (LSRO) provides scientific assessments of topics in the biomedical sciences. Assessments are based on comprehensive literature reviews and the scientific opinions of knowledgeable investigators who work in relevant areas of science and medicine.

This report, which is one of several reports of the LSRO Reduced Risk Review Project (RRRP), was developed under a contract between Philip Morris USA, Inc. (Philip Morris) and LSRO. The findings, conclusions, and recommendations contained in these RRRP reports were developed independently of Philip Morris and are not intended to represent the views of Philip Morris or any of its employees.

This report provides the overall conclusions and recommendations of LSRO on scientific methods and approaches to evaluate tobacco products that might pose lower health risks than conventional cigarettes. The other reports provide additional detail on the state-of-the-science related to critical components of the RRRP.

Several Expert Advisory Committees provided scientific oversight and direction for all aspects of this project. LSRO independently appointed Expert Advisory Committee members based on their qualifications, experience, judgment, and freedom from conflict of interest; balance and breadth in appropriate professional disciplines were also considered. Committee members were selected with the concurrence of the LSRO Board of Directors. Appendix A provides an overview of the scientific expertise of LSRO staff and Expert Advisory Committee members; additional biographical and professional information for each Committee member is also included.

LSRO invited submission of data, information, and views bearing on the topic under study, held a widely advertised Open Meeting on April 27, 2005, and accepted written and electronic submissions. The Expert Advisory Committees convened 18 times between February 2005 and November 2006 to assess the available data. Information about the process, including critical literature and presentations upon which the Expert Advisory Committees based their deliberations, was made publicly available on the LSRO web site at www.lsro.org/rrrvw.

LSRO staff drafted this report based on available information, deliberations of the Expert Advisory Committees, and recommendations of the RRRP Core Committee. The draft LSRO RRRP report was submitted to experts in

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. relevant disciplines for independent peer review, and their comments were considered for incorporation by LSRO staff, the RRRP Core Committee, and the LSRO Board of Directors. Philip Morris reviewed the final report for technical accuracy with respect to its products or other possible factual errors. The RRRP Core Committee and LSRO Board of Directors reviewed and approved the final report.

Participation in the preparation of this report or membership on an Expert Advisory Committee, or the LSRO Board of Directors does not imply endorsement of all statements in the report. LSRO accepts full responsibility for the study conclusions and accuracy of the report.

Michael Falk, Ph.D. Executive Director Life Sciences Research Office, Inc. January 24, 2007

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Table of Contents v TABLE OF CONTENTS

FOREWORD ...... iii

EXECUTIVE SUMMARY ...... 1

I. INTRODUCTION ...... 8 I.1 PROJECT PURPOSE AND GOALS...... 9 I.2 REDUCED RISK REVIEW PROJECT CONTEXT...... 9 I.2.1 Public Health Context ...... 10 I.2.2 Public Policy Context ...... 12 I.2.3 Scientific Context ...... 16 I.3 REDUCED RISK REVIEW PROJECT ANALYTICAL FRAMEWORK...... 16 I.3.1 Individual Risk Assessment ...... 16 I.3.2 Population Risk Assessment ...... 18 I.4 EXPERT ADVISORY COMMITTEES ...... 18 I.4.1 Core Committee ...... 18 I.4.2 State-of-the-Science Review Committees ...... 19 I.5 SELECTION OF DISEASE ENDPOINTS ...... 20 I.6 SELECTION OF CONTROL PRODUCTS ...... 20 I.7 INITIAL AREAS OF CONSENSUS ...... 24 I.8 REPORT ORGANIZATION ...... 24

II. PRECLINICAL STUDIES ...... 25 II.1 INTRODUCTION ...... 26 II.2 PRODUCT CHARACTERISTICS ...... 26 II.3 CHEMISTRY ...... 28 II.3.1 Mainstream Smoke ...... 28 II.3.2 Environmental Tobacco Smoke ...... 33 II.4 CYTOTOXICITY AND GENOTOXICITY ASSAYS...... 34 II.5 ANIMAL STUDIES ...... 37 II.5.1 Study Selection and Design ...... 37 II.5.2 Animal Models of Human Disease ...... 40 II.6 CONCLUSIONS AND RECOMMENDATIONS ...... 44

III. CLINICAL STUDIES ...... 45 III.1 INTRODUCTION ...... 46 III.1.1 Biomarkers...... 46 III.1.2 Clinical Study Design ...... 48

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III.2 CLINICAL STUDIES OF EXPOSURE ...... 49 III.2.1 Biomarkers of Exposure ...... 49 III.2.2 Smoking Topography ...... 53 III.2.3 Other Measures of Exposure ...... 56 III.2.4 Interpretation of Exposure Study Results ...... 56 III.3 CLINICAL STUDIES OF EFFECT ...... 57 III.3.1 Biomarkers of Effect ...... 57 III.3.2 Selection of Biomarkers of Effect...... 63 III.4 CONCLUSIONS AND RECOMMENDATIONS ...... 65

IV. COMPARATIVE RISK ASSESSMENT ...... 66 IV.1 INTRODUCTION ...... 67 IV.1.1 Context and Purpose of a Risk Assessment ...... 67 IV.1.2 Treatment of Scientific Uncertainty ...... 67 IV.1.3 Weight of Evidence ...... 68 IV.1.4 PRRTP Risk Assessments ...... 69 IV.2 EXPOSURE ASSESSMENT ...... 71 IV.2.1 Human Biomarker Studies ...... 71 IV.2.2 Smoking Topography ...... 71 IV.2.3 Chemistry Studies ...... 71 IV.2.4 Weight of Evidence: Exposure ...... 72 IV.3 BIOLOGICAL EFFECTS ASSESSMENT ...... 72 IV.3.1 Clinical Studies of Biomarkers of Effect ...... 72 IV.3.2 Preclinical Studies ...... 73 IV.3.3 Weight of Evidence: Biological Effects Assessment ..... 73 IV.4 RISK CHARACTERIZATION ...... 73 IV.5 CONCLUSIONS AND RECOMMENDATIONS ...... 78

V. POPULATION RISK ASSESSMENT ...... 79 V.1 INTRODUCTION ...... 80 V.2 COMPONENTS OF POSTMARKETING EVALUATION ...... 81 V.3 CLINICAL STUDIES OF EXPOSURE AND EFFECT ...... 81 V.4 BEHAVIORAL ASSESSMENTS ...... 81 V.4.1 Unintended Users ...... 82 V.4.2 Study Participants...... 83 V.4.3 Study Methods...... 85 V.5 SURVEILLANCE AND EPIDEMIOLOGIC STUDIES ...... 88 V.6 CONCLUSIONS AND RECOMMENDATIONS ...... 89

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VI. SCIENCE AND POLICY IN PRRTP DECISION MAKING ...... 90 VI.1 INTRODUCTION ...... 91 VI.2 CURRENT TOBACCO CONTROL POLICIES FOR SMOKELESS TOBACCO PRODUCTS ...... 91 VI.2.1 Definition of Smokeless Tobacco Products...... 92 VI.2.2 Smokeless Tobacco and Risk Reduction: Scientific Evidence ...... 92 VI.2.3 Smokeless Tobacco and Risk Reduction: Public Policies ...... 92 VI.3 VALIDITY OF TOBACCO CONTROL POLICY ...... 94 VI.3.1 Scientific Validity ...... 94 VI.3.2 Ethical Validity ...... 94 VI.4 DISCUSSION ...... 95

VII. LITERATURE CITATIONS ...... 96 TABLES Table I-1. Examples of Potential Reduced-Risk Tobacco Products ...... 15 Table I-2. Summary of Regulatory and Other Legal Considerations to PRRTP Claims ...... 17 Table I-3. Diseases and Other Adverse Health Effects for Which Smoking is Identified as a Cause in the 2004 Surgeon General Report ...... 21 Table I-4. Risks of the Three Most Common Causes of Death in Smokers ...... 24 Table II-1. Examples of PRRTP Modifications and Associated Chemical Analyses ...... 27 Table II-2. Cigarette-Smoking Machine Methods ...... 29 Table II-3. Cytotoxicity and Genotoxicity Assays ...... 35 Table II-4. Animal Study Types Commonly Used to Assess Cigarettes ...... 38 Table II-5. Disease-Specific Animal Models ...... 41 Table III-1. Considerations for Biological Sample Matrices for Studies of Biomarkers of Exposure ...... 50 Table III-2. Biomarkers of Tobacco Smoke Exposure Recommended for Routine Use ...... 52 Table III-3. Biomarkers of Tobacco Smoke Exposure Not Recommended for Routine Use ...... 54 Table III-4. Sample Battery of Biomarkers of Tobacco Smoke Exposure ...... 56 Table III-5. Biomarkers for Measuring Biological Effect ...... 59 Table III-6. Examples of a Battery of Biomarkers of Effect for LC, COPD, and CVD ...... 64

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Table IV-1. An Example of Scientific Uncertainties and Assumptions ..... 68 Table IV-2. Steps in the FDA Process Applied to PRRTPs...... 70 Table IV-3. Sample of Risk Characterization Summary...... 75

FIGURES Figure 1. LSRO Framework for the Premarketing Evaluation of a Potential Reduced-Risk Tobacco Product...... 5 Figure 2. LSRO Testing Approaches for a Potential Reduced-Risk Tobacco Product ...... 7 Figure I.1. Annual Statistics Associated with Cessation in the United States...... 11 Figure III.1. Biomarkers of Exposure and Effect ...... 47

VIII. APPENDICES ...... 137 VIII.A LIFE SCIENCES RESEARCH OFFICE (LSRO) ...... 137 VIII.A.1 Reduced Risk Review Project Core Committee ...... 137 VIII.A.2 State-of-the Science Review Committees ...... 141 VIII.A.2.1 Exposure Assessment Committee ...... 141 VIII.A.2.2 Biological Effects Assessment Committee ...... 144 VIII.A.2.3 Population Effects and Behavior Assessment Committee ...... 148 VIII.A.3 Life Sciences Research Office Staff ...... 151 VIII.A.4 Life Sciences Research Office Board of Directors...... 156 VIII.B GLOSSARY/ACRONYMS ...... 157 VIII.B.1 Glossary ...... 157 VIII.B.2 Acronyms ...... 170

INDEX ...... 172

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. EXECUTIVE SUMMARY This report provides Life Sciences Research Office (LSRO)1 findings and recommendations on scientific methods to evaluate tobacco products that may pose lower health risks to individuals who use them instead of conventional cigarettes. The term “Potential Reduced-Risk Tobacco Product” (PRRTP) is used in this report to refer to these products. This report was developed under a contract between Philip Morris USA, Inc., (Philip Morris) and LSRO. The findings, conclusions, and recommendations contained herein were developed independently of Philip Morris and are not intended to represent the views of Philip Morris or any of its employees.

BACKGROUND According to estimates by the Centers for Disease Control and Prevention (CDC), more than 400,000 people die each year in the US as a result of past or current cigarette smoking; adult smokers lose an average of 13–15 years of life because they smoke (Centers for Disease Control and Prevention, 2002); and smoking adversely impacts the health of non-smokers who are exposed to environmental tobacco smoke (ETS), with an estimated 38,000 “passive smokers” dying each year of diseases caused by ETS (U.S. Department of Health and Human Services, 2006).

Despite widespread knowledge of the risks posed by cigarette smoking, approximately one in five US adults (approximately 44.5 million people) smokes (Centers for Disease Control and Prevention, 2002). The number of smokers increases to 59.9 million if adolescents are included (Substance Abuse and Mental Health Services Administration, 2004).

The most effective means to eliminate or decrease risk of dying due to smoking is to stop using cigarettes. According to a CDC report, although 70% of smokers want to stop smoking each year and 34% of all smokers attempt to quit, only 2.5% of all smokers are successful (Centers for Disease Control and Prevention, 2004). Unfortunately, because it is very difficult to remain tobacco-free, approximately one-third of those who quit for one year resume smoking within the following 12 months (Henningfield et al., 1998).

The addictive nature of nicotine contributes significantly to the difficulty of cessation (Benowitz, 1996). Nicotine replacement therapies (NRT), such

1 For the remainder of this report, LSRO, its staff, and the expert advisory “Core Committee (CC),” are referred to collectively as “LSRO”.

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as the nicotine patch, assist in cessation, as do behavioral support programs (Giovino et al., 1995); however, the statistics on cessation clearly demonstrate that the difficulties associated with quitting remain.

The low success rate for smoking cessation makes tobacco harm reduction (THR), intended to reduce adverse health effects to smokers who will not or can not abstain, a potentially valuable component of a comprehensive tobacco control program2 (Boyle et al., 2004; Institute of Medicine, 2001; Warner, 2002).

In 1999, the US Food and Drug Administration commissioned a study by the Institute of Medicine (IOM), Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction (Institute of Medicine, 2001). The purpose of this study was to “formulate scientific methods and standards by which ‘potential reduced-exposure products (PREPs)’ [tobacco-based and other products such as NRT] could be assessed.”

The IOM report endorsed the concept of THR including PREPs as a part of a comprehensive tobacco control program. It also stressed the importance of adequate scientific evaluations of the effects of PREPs on exposure and risk and comprehensive regulation of tobacco products (Institute of Medicine, 2001).

LSRO STUDY OBJECTIVES AND APPROACH LSRO reviewed scientific methods and approaches for evaluation of the effects of using PRRTP on exposure and risk compared to smoking conventional cigarettes. Specific Reduced Risk Review Project (RRRP) objectives were to: • Identify the types of scientific information needed to assess risk reduction; • Establish criteria to evaluate the scientific information, including identification of comparison products [controls]; and • Define a review process for the scientific information.

Because the RRRP focused on scientific methods to evaluate PRRTPs, LSRO makes no recommendations concerning public policy, such as regulatory approaches; however, LSRO recognizes that public policy will affect the acceptance and use of scientific information in decision making.

2 All forms of tobacco use are associated with serious health consequences; however, the most popular and most deadly form is the cigarette (Doll, 2004). As a result, THR efforts focus largely on cigarette smoking.

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LSRO addressed two types of assessments that are related to PRRTPs: • Individual Risk Assessment. The primary focus of the RRRP was the identification and critical assessment of scientific information that could be used prior to product marketing to determine whether a PRRTP is likely to reduce risk for individual smokers who use it instead of conventional cigarettes. • Population Risk Assessment. LSRO also reviewed scientific methods to assess the health effects of a PRRTP on the population as a whole. The goals of a population risk assessment are to determine whether anticipated improvements in the health status of smokers who use a PRRTP are realized, whether prevalence of tobacco use (and associated health risks) among individuals who would otherwise be tobacco free is increased by PRRTP use, and whether net effects on public health are positive.

MAJOR CONCLUSIONS AND RECOMMENDATIONS Individual Risk Assessment Objective 1: Identify the types of scientific studies needed to assess risk reduction. LSRO concluded that reliable testing and assessment methods for individual risk reduction are currently available for premarket evaluation of PRRTPs.

Prior to marketing, evidence that risk is likely to be reduced in smokers who switch to a PRRTP is, of necessity, indirect: diseases associated with cigarette smoking that are most responsible for premature death are chronic, requiring years, and in some cases, decades, to develop. A weight of evidence approach that includes preclinical and clinical studies of sufficient quantity, quality, and relevance to the population of smokers likely to use a PRRTP can provide reliable conclusions on the potential for risk reduction.

LSRO concluded that PRRTP assessments should focus on the risks posed by the three most deadly diseases caused by cigarette smoking: lung cancer (LC), chronic obstructive pulmonary disease (COPD), and cardiovascular disease (CVD).

The rationale for this conclusion is two-fold: (1) scientific assessment of all diseases and conditions identified by the Surgeon General as caused by cigarette smoking is not feasible; and (2) approximately 90% of the estimated 400,000 annual smoking-related deaths of current or former smokers in the

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US are due to LC, COPD, and CVD (Centers for Disease Control and Prevention, 2005c).

LSRO concluded that the data needed to evaluate risk reduction of PRRTP use in individual smokers must be derived from comprehensive preclinical and clinical testing.

Preclinical studies that are required to fully evaluate a PRRTP include product characterizations, smoke chemistry studies, cytotoxicity and genotoxicity assays, and animal studies. Clinical studies that are required include studies of biomarkers of exposure for critical emission constituents and whole smoke and studies of biomarkers of effects associated with the risk of developing LC, COPD, and/or CVD.

Objective 2: Establish criteria to evaluate the scientific information, including identification of comparison products. LSRO relied on evaluation criteria that are widely used to assess preclinical and clinical study results for such purposes as evaluating the safety of consumer products and establishing regulatory limits for occupational and environmental exposures to toxic chemicals.

LSRO’s data evaluation criteria included the following considerations: study type conducted; number and quality of studies; degree of consistency of findings across similar studies; and relevance of the study results to humans.

LSRO identified two broad categories of product controls for PRRTPs: reference cigarettes and commercially available, conventional cigarettes.

Objective 3: Define a process to review the scientific information. LSRO used a risk assessment approach to evaluate PRRTPs.

PRRTP risk assessments compare exposures to toxic constituents present in PRRTP emissions with those associated with smoking conventional cigarettes and biological effects associated with disease risk in PRRTP users with those in users of conventional cigarettes. The overall evaluation approach developed by LSRO to assess individual risk reduction is summarized in Figure 1. LSRO identified critical questions to be answered in the decision making (“risk management”) for PRRTPs (third column in Figure 1) and then developed testing and comparative risk assessment approaches to provide the necessary information to decision makers.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Executive Summary 5 (Risk Management) DECISION MAKING Does the evidence support a health-related claim? If yes: Identify options for the following questions: claim? Claim? Language of Need to disclose scientific claim? of limitations Marketing approaches? Packaging? Evaluate public health, behavioral, and legal, social, other relevant considerations associated with each option. Select option(s). Risk Characterization What is the weight of evidence for reduced exposure and reduced risk associated with use of a PRRTP? COMPARATIVE RISK ASSESSMENT Exposure Assessment Is there evidence that replacing conventional cigarettes with a PRRTP reduces to toxicants? exposure Biological Effects Assessment Is there evidence that replacing conventional cigarettes with a PRRTP results in changes in biological effects that indicate reduced risk? LSRO framework for the premarketing evaluation of a potential reduced-risk tobacco product (PRRTP). evaluation the premarketing for framework LSRO TESTING Preclinical Studies Studies Clinical of Exposure Studies Clinical of Effect Figure 1. Figure 1.

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Population Risk Assessment LSRO concluded that a combination of clinical, behavioral, and epidemiologic methods are needed to determine the effects of a PRRTP on population risk.

The effect of introducing a PRRTP on the population as a whole is determined by the degree to which it reduces overall morbidity and mortality. A PRRTP that decreases risk for individuals who use the PRRTP instead of smoking conventional cigarettes could also increase risk for individuals who use the PRRTP instead of remaining tobacco-free. Both decreases and increases in risk must be examined to determine the net effect on population risk.

Appropriately controlled clinical studies of exposure and effect in intended users (smokers who can not or will not quit) and behavioral assessments and surveys of tobacco use and attitudes in unintended users (individuals who would otherwise be tobacco free) can provide early indicators of population effects of a PRRTP. Epidemiologic studies of sufficient duration will be required to provide more definitive evidence of population health effects.

LSRO concluded that postmarketing evaluations will be necessary to obtain adequate and reliable data to assess potential increases in population risk.

LSRO reviewed premarketing assessment methods that might be used in the evaluation of potential increased tobacco use/risk in individuals who would otherwise be tobacco free and concluded that currently available methods are not adequate to predict potential adverse effects of PRRTP use on population risk. While behavioral studies used to assess the potential for increased use of tobacco products can be conducted prior to marketing a PRRTP, the potential for tobacco-free individuals to use a PRRTP will depend on a number of factors that will be known only after the product is marketed, such as the physical and sensory properties of the PRRTP and marketing strategies and imagery used to promote the product.

Therefore, planned postmarketing population assessment studies are necessary to detect unintended public health consequences that may result from the introduction of a PRRTP.

Summary of LSRO Approach to the Evaluation of PRRTP A schematic depiction of pre- and postmarket testing and evaluation approaches recommended by LSRO is presented in Figure 2.

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Methods to assess : lung cancer. : LC Postmarket Clinical studies, behavioral studies and surveys, epidemiological studies Objectives: Evaluate and monitor effects on individual risk reduction, tobacco use attitudes and behaviors, and population risk : chronic obstructive pulmonary disease, pulmonary chronic obstructive disease, : Premarket . (2005a). Reproduced by permission of Taylor & Francis Group Ltd., http:// & Francis Taylor permission Reproduced by of (2005a). . COPD

et al Clinical studies of exposure and biological effects Objectives: Conduct clinical biomarker studies in smokers to compare the effects of a PRRTP on exposure and biological effects associated with LC, COPD, CVD with those of conventional cigarettes by Hatsukami by : cardiovascular disease, disease, cardiovascular : CVD Premarket Preclinical evaluation Clinical evaluation Postmarketing evaluation Smoke chemistry studies, cytotoxicity and genotoxicity assays, and animal testing Objectives: Conduct screening studies to determine whether a PRRTP has a reasonable likelihood of reducing disease risks in smokers LSRO testing approaches for a potential reduced-risk tobacco product (PRRTP). Copyright 2005 adapted from Copyright a potential reduced-risk tobacco product (PRRTP). testing approaches for LSRO Figure 2. potential reduced exposure products potential reduced exposure www.tandf.co.uk/journals.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. INTRODUCTIONI I. INTRODUCTION

I.1 PROJECT PURPOSE AND GOALS

I.2 REDUCED RISK REVIEW PROJECT CONTEXT I.2.1 Public Health Context I.2.2 Public Policy Context I.2.2.1 Tobacco harm reduction I.2.2.2 Legal oversight of PRRTP claims I.2.3 Scientific Context

I.3 REDUCED RISK REVIEW PROJECT ANALYTICAL FRAMEWORK I.3.1 Individual Risk Assessment I.3.1.1 Risk reduction I.3.1.2 Harm reduction I.3.2 Population Risk Assessment

I.4 EXPERT ADVISORY COMMITTEES I.4.1 Core Committee I.4.2 State-of-the-Science Review Committees I.4.2.1 Exposure Assessment Committee I.4.2.2 Biological Effects Assessment Committee I.4.2.3 Population Effects and Behavior Assessment Committee I.4.2.4 General approaches used by Committees

I.5 SELECTION OF DISEASE ENDPOINTS

I.6 SELECTION OF CONTROL PRODUCTS

I.7 INITIAL AREAS OF CONSENSUS

I.8 REPORT ORGANIZATION

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Introduction 9 INTRODUCTIONI I.1 PROJECT PURPOSE AND GOALS The purpose of the Reduced Risk Review Project (RRRP) was to develop an approach to scientifically evaluate and assess the risk-reduction characteristics of potential reduced-risk tobacco products (PRRTP). Specific goals included: • Identification of the types of scientific information needed to assess risk reduction; • Establishment of criteria to evaluate the scientific information, including identification of comparison products [controls]; and • Definition of a review process for the scientific information.

Life Sciences Research Office (LSRO) relied on input from several Expert Advisory Committees, the members of which were selected by LSRO staff and approved by the LSRO Board of Directors. The Committee members met requirements for expertise that LSRO identified as necessary to complete the RRRP (e.g., risk assessment, public health policy/regulation, medicine/clinical practice, epidemiology, toxicology, biostatistics, chemistry, physiology, biomarkers of exposure and biological effect, human behavior, and pharmacology). Potential committee members were required to disclose any past or present affiliations with the tobacco industry and this information was taken into consideration in the final selection process. The qualifications of Expert Advisory Committee members are provided in Appendix A.

I.2 REDUCED RISK REVIEW PROJECT CONTEXT Scientific assessments occur within particular contexts. The public health context of the RRRP is defined by the tension between two facts: cigarette smoking is the number one preventable cause of death and disease in the US; yet, approximately one-fifth of all US adults continue to smoke3. The public policy context focuses on the use of health-related claims made for PRRTPs, and is extremely controversial (Institute of Medicine, 2001). Finally,

3 The RRRP has focused on the state of affairs in the United States; however, the issues addressed are not unique to this country.

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the scientific context is characterized by the “urgent need” to evaluate PRRTPs in the face of scientific uncertainty (Institute of Medicine, 2001).

I.2.1 Public Health Context In the US, an estimated 400,000 current and former smokers die each year from smoking-related diseases (American Lung Association, 2006; Centers for Disease Control and Prevention, 2002; Centers for Disease Control and Prevention, 2005c).4 Additionally, approximately 38,000 nonsmokers who have been chronically exposed to environmental tobacco smoke (ETS) die each year from smoking-related disease (Centers for Disease Control and Prevention, 2002).

Approximately 20.9% of US adults (44.5 million individuals) smoke cigarettes (Centers for Disease Control and Prevention, 2005a). Each year, approximately one million individuals (mostly adolescents) in the US become daily smokers (U.S. Department of Health and Human Services, 2004a).

Although millions of individuals have stopped smoking since the release of the first US Surgeon General’s Report (U.S. Department of Health Education and Welfare, 1964) (with the greatest reductions occurring between 1975 and 1990), there has been little change in the number of smokers since 1990 (American Lung Association, 2006; United Health Foundation et al., 2005).

Based on data released by the Centers for Disease Control and Prevention (2004), although 31 million adult smokers want to stop smoking and 15 million attempt to quit each year, only one million succeed5 (Figure I.1). Approximately one third who successfully quit resume smoking with in the following 12 months (Henningfield et al., 1998).

4 Worldwide, smoking-related deaths are estimated at 4–5 million annually (Boyle et al., 2004; World Health Organization, 2006). Annual deaths caused by smoking cigarettes are anticipated to reach 10 million by 2030 (Peto & Lopez, 2004). 5 Successful cessation is defined as abstinence from smoking for at least 6 months (Centers for Disease Control and Prevention, 2005a). Former smokers are defined as those who reported smoking >100 cigarettes during their lifetime but who currently do not smoke (Centers for Disease Control and Prevention, 2005b).

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Introduction 11 1.1 (2.5%) 15.1 Adapted from Centers for Disease Control and Adapted from Centers for (34%)

31 (70%) Desire to Quit Quit Attempt to Quit

44.5 (100%) Smokers

5 0

50 45 40 35 30 25 20 15 10 presents annual statistics associated with cessation in the United States. presents annual

Millions Prevention (2004). Prevention Figure I.1

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I.2.2 Public Policy Context I.2.2.1 Tobacco harm reduction Due to the low success rate of smoking cessation and the high number of continuing smokers, THR, which is aimed at reducing adverse health impacts for smokers who will not or can not abstain from using tobacco, is being considered as a component of a comprehensive tobacco control program (Institute of Medicine, 2001).

The concept of harm reduction is not new. Harm reduction approaches or products are used in an environment where harm is present/occurs. Put simply, harm reduction is needed when harm cannot be either prevented or eliminated. Current examples of harm reduction in the practice of medicine include interventions for illicit drug use and alcohol abuse, and the regulation of a variety of health hazards (e.g., food contamination, environmental pollution). This report focuses on THR for continuing cigarette smokers who can not or will not quit.

In the book Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors (Marlatt, 1998), Baer and Murch (1998) identified four broad categories of THR strategy: limiting access, altering use patterns, changing the nature of the product, and replacing nicotine. The authors also noted that effective THR for the widest range of continuing smokers would employ combinations of these strategies.

In the following discussion, “altering use patterns” includes the “replacing nicotine” category as well as a discussion of medications that aid in cessation but do not replace nicotine.

Limiting access Access can be limited by (1) not selling the product (it is illegal to sell tobacco products to individuals under 18 years of age in the US) (U.S. Department of Health and Human Services, 1996); (2) reducing physical availability (e.g., removal of vending machines); (3) increasing the cost of cigarettes (younger smokers are more responsive to increased cost than older smokers) (Ding, 2003); and (4) prohibiting smoking in public places (Bauer et al., 2005; Fichtenberg & Glantz, 2002).

Altering use patterns Altered use patterns that reduce harm include cessation and reduced levels of smoking. Cessation rates are increased by use of psychosocial treatment

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(e.g., programs to help smokers quit) (Fiore et al., 2000); use of a nicotine- replacement therapy (NRT) (e.g., nicotine gum, patches, nasal sprays) (Fagerström, 2003; Foulds et al., 2006; Mitrouska et al., 2006); and use of non-nicotine pharmacotherapy–for example, antidepressants such as Bupropion (Zyban®) to treat nicotine dependence (Fagerström & Balfour, 2006; Frishman et al., 2006; Mitrouska et al., 2007) and nicotinic receptor agonists such as Varenicline (Chantix®), a partial agonist at the α2β4 nicotinic receptor (Pfizer, 2006).

When full cessation is not achieved, reducing the number of cigarettes smoked per day (“controlled smoking”) in dependent smokers has also been explored as an approach to harm reduction (Hatsukami et al., 2005b; Rennard et al., 1990). Successful reduction has been reported in several studies (Baer & Murch, 1998; Bolliger et al., 2002; Colletti et al., 1982; Levinson et al., 1971; Shapiro et al., 1971). Recent studies examining the use of NRT to reduce smoking in dependent smokers (a use that is currently not US Food and Drug Administration (FDA)-approved) have also reported reduced cigarette consumption and biomarkers of exposure to tobacco smoke constituents (Fagerström & Hughes, 2002; Fagerström et al., 1997; Hecht et al., 2004; Hecht et al., 2005; Wennike et al., 2003).

Although some investigations show success of NRT use in the maintenance of abstinence or reduced levels of smoking (Cummings & Hyland, 2005; Fagerström et al., 1997; Gray, 2004), other studies show NRT having limited success in achieving smoking cessation on a long-term basis (Carrera et al., 2004; Haxby, 1995; Sweeney et al., 2001; Thompson & Hunter, 1998; Zevin et al., 1998).

Changing the nature of the product Methods to change the nature of the product include adding filters and developing reduced-yield cigarettes. PRRTPs fall within this category of THR.

Addition of filters The introduction of filters and changes in tobacco pressing in the 1950s significantly reduced the amount of tar in mainstream cigarette smoke (Russell, 1993; Wald et al., 1981a). Epidemiologic evidence has shown that these changes may have reduced the risk of lung cancer in smokers by up to 50% (Peto, 1986).

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Reduced-yield cigarettes In the late 1960s, a program to develop a “less hazardous cigarette” was undertaken by the US Public Health Service in conjunction with the tobacco industry and others (Parascandola, 2005). The program was based on the premise that reduced particulate matter (tar) in smoke (reduced-yield) would expose smokers to lower levels of carcinogens, which would reduce the risk of lung cancer (Gori, 1976). Several decades after the introduction and widespread consumer acceptance of reduced-yield cigarettes (Federal Trade Commission, 2000), Samet (1995) reviewed epidemiologic data on the disease risks associated with reduced-yield cigarettes and reported that modest decreases (less significant than anticipated) in lung cancer risk were associated with reduced-yield cigarettes.

PRRTPs Table I-1 includes brief descriptions of PRRTPs that have been developed and/or marketed (with or without health-related claims).

Although many products in Table I-1 have not been commercially successful, a number of tobacco companies have active research programs to develop new PRRTP that continuing smokers will accept and use (22nd Century Limited, 2005; British-American Tobacco Co. Ltd., 2005; Philip Morris USA, 2006a; Star Scientific Inc., 2005).

Table I-1 includes two broad PRRTP categories: smoked and smokeless. This report is focused on products intended to be used like a cigarette (i.e., smoked). LSRO believes that smokeless tobacco (ST) products, for which a claim of reduced risk is being contemplated by manufacturers, should be evaluated prior to making such a claim. LSRO excluded this category of PRRTP because assessment methods will differ from those needed to assess smoked PRRTPs, and time and resources were insufficient to develop two evaluative processes.

I.2.2.2 Legal oversight of PRRTP claims The Institute of Medicine (IOM) and others have identified the decision to make a health-related claim as the most critical decision for PRRTPs (Institute of Medicine, 2001; Philip Morris USA & Gaworski, 2005; Warner, 2005). In the US, product claims are regulated by the Federal Trade Commission (FTC), which requires that evidence substantiating a claim be available at the time the claim is made (Federal Trade Commission, 1983b). In addition, individual states and individual citizens can take legal action against the manufacturer for product claims on the grounds that the claims

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Table I-1. Examples of Potential Reduced-Risk Tobacco Products PRRTP Modification US Market Status Smoked Products Accord® Heats but does not burn tobacco. In test market: Heating occurs only when the cigarette Richmond, VA is puffed while inserted into a microchip- controlled, battery-operated, hand-held device (Philip Morris USA, 2001) Advance® Includes a 3-part “Trionic” filter Not on the market containing cellulose acetate, a carbon compound, and an ion exchange resin. Contains StarCure™ tobacco, which has reduced levels of TSNAs (Brown & Williamson Tobacco, 2002) Eclipse®/Premier®a Primarily heats tobacco. “Eclipse is On the market designed to burn only 3% as much tobacco as other cigarettes” (R.J. Reynolds Tobacco Company, 2006) OMNI® Contains tobacco cured under modified Not on the market conditions and treated with catalysts to reduce levels of carcinogens; uses a carbon filter (Vector Tobacco, 2001a,b) Quest® Contains genetically modified tobacco On the market: NY, lacking an important gene for nicotine NJ, PA, OH, IN, IL, MI synthesis (Vector Tobacco, 2006) and AZ Marlboro UltraSmooth® Cigarette contains a novel carbon filter In test market: Atlanta, (Beran, 2005) GA; Tampa, FL; and Salt Lake City, UT Smokeless Products Ariva® Lozenge made of ground powdered On the market StarCure™ tobacco (Star Scientific, 2002). Ariva is a pouchless tobacco product that dissolves in the mouth, requiring no spitting (Star Scientific, 2006) Exalt® Snus-like tobacco product with reduced On the market levels of TSNAs, sold as a pouch (Swedish Match, 2001) Stonewall® Contains tobacco with reduced levels of On the market: TX, TSNAs. A pouchless tobacco product VA, LA, MS, FL, MN, that dissolves in the mouth, requiring no MI and IN; in test spitting. (Star Scientific, 2006) market: Louisville, KY Taboka® A smoke-free, spit-free tobacco pouch In test market: designed especially for adult smokers Indianapolis, IN interested in smokeless tobacco alternatives (Philip Morris USA, 2006b)

aPremier® was an earlier version of Eclipse®. TSNAs: tobacco-specific nitrosamines (suspected human carcinogen)

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are not adequately supported by scientific evidence. For example, the State of Vermont recently filed suit against RJ Reynolds Tobacco Company over claims made for Eclipse®. Table I-2 provides a brief overview of regulatory/ legal authority over claims made for PRRTPs.

I.2.3 Scientific Context In 1999, the FDA commissioned a study by the IOM of scientific methods to assess the effects of “potential reduced-exposure products” (PREPs) which culminated in the IOM report, Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction (Institute of Medicine, 2001).

In this study, IOM coined the term PREP to refer to tobacco products or NRT that could potentially result in reduced exposure to smoke toxicants. The term ‘PREP’ (as opposed to “potential reduced-risk product” or “PRRP”) reflects IOM conclusions that the state-of-the-science for the assessment of these products would, at best, identify products with the potential to reduce exposure (Warner, 2002) and that reduced exposure does not assure reduced risk to the individual user or reduced harm to the larger population.

The IOM study also included: • There is an urgent need to evaluate PREPs; • Exposure and risk reduction by PREPs are feasible; but • The scientific tools needed to assess the effects of PREPs in the near term (e.g., prior to marketing) are not adequately validated.

I.3 REDUCED RISK REVIEW PROJECT ANALYTICAL FRAMEWORK I.3.1 Individual Risk Assessment LSRO used a testing/risk assessment/risk management framework developed by a National Research Council committee (National Research Council, 1983) to systematically evaluate scientific data associated with PRRTPs.

I.3.1.1 Risk reduction Risk is the probability that harm (e.g., smoking-related disease) will occur. The risk-reduction potential of a PRRTP can be evaluated using preclinical and clinical experimental data generated prior to product marketing. If a product has been adequately tested and the evidence is sufficiently strong, a determination of the likelihood that risk will be reduced in individuals who

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Table I-2. Summary of Regulatory and Other Legal Considerations Related to PRRTP Claims

Federal Trade Commission

1) The FTC has jurisdiction to proscribe “unfair or deceptive acts or practices.” Pursuant to this authority, the FTC can challenge health or safety claims for consumer products such as reduced-risk tobacco products which are either deceptive or unfair (Federal Trade Commission, 1980a).

2) For a practice or a claim to be deceptive, the FTC requires that: x There be a representation, omission, or practice that is likely to mislead the consumer; x The practice be examined from the perspective of a consumer acting reasonably in the circumstances; and x The representation, omission, or practice must be “material” (Federal Trade Commission, 1983a).

3) A claim, which can be either express or implied, can be found to be deceptive if there does not exist a “reasonable basis” for the claim at the time it is made. [(Federal Trade Commission, 1983a). The “reasonable basis” requirement.]

4) The Federal Trade Commission can also challenge a claim as deceptive if it fails to make an affirmative disclosure of qualifying information, the absence of which would render the claim misleading to consumers.

State Authority

Most states exercise very similar authority under “little FTC Acts.” Thus, a state Attorney General might also challenge a claim. Generally, states apply the same analytical methodology and standards as does the FTC, but there may be occasional differences in approach or results, particularly when significant public policy issues are involved (see ABA Section of Antitrust Law, Antitrust Law Developments, 5th ed., 2002 at 723).

Private Litigation

A private litigant (such as a manufacturer of a competing product) can challenge deceptive product claims and recover damages resulting from false advertising (see Section 43(a) of the Lanham Act, 15 U.S.C. 1125(a)).

Health and safety claims can also be involved in product liability litigation, which uses different legal criteria (see generally, American Law Institute, Restatement of the Law Third, Torts: Products Liability, 2002).

ABA: American Bar Association; FTC: Federal Trade Commission; PRRTP: potential reduced-risk tobacco product

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use the PRRTP, rather than conventional cigarettes, can be made prior to marketing.

I.3.1.2 Harm reduction Harm is an adverse event, such as a disease or health condition (in this case, caused by exposure to tobacco smoke). A tobacco product that reduces harm compared to conventional cigarettes would reduce disease incidence and mortality within defined populations (e.g., users of the product, individuals passively exposed to smoke toxicants, and/or the entire population). Harm reduction is measured directly in populations of interest using epidemiologic and prospective clinical studies after a product has been marketed and used by the public.

I.3.2 Population Risk Assessment Demonstration of reduced risk of smoking-related diseases in continuing smokers who use a PRRTP does not necessarily mean that risk will be reduced for the overall population. If others who would be tobacco-free in the absence of a PRRTP initiate or continue tobacco use by switching to a PRRTP, the benefit to continuing smokers who switch could be offset to some degree or even exceeded by the risks to those who otherwise would not have begun or would have quit smoking entirely. Therefore, LSRO also evaluated methods that could be used to assess the overall impact of a PRRTP on population risk.

I.4 EXPERT ADVISORY COMMITTEES LSRO established four Expert Advisory Committees: a Core Committee and three State-of-the-Science Review Committees.

I.4.1 Core Committee The Core Committee (CC) provided oversight and guidance for overall conduct of the RRRP and assisted in the preparation of the project report. The CC was also specifically charged to identify the necessary elements of an evaluative process and to assist in the formation and oversight of the State-of-the-Science Review Committees (SSRC). The CC reviewed the scopes of work and tracked the progress of each SSRC. Members of the CC served as liaisons to the SSRCs, with at least two CC members participating in each SSRC meeting. The CC provided feedback to the SSRCs and was responsible for the evaluation and incorporation of SSRC findings in this final report.

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I.4.2 State-of-the-Science Review Committees The SSRCs contributed summaries of their reviews to this report and developed detailed separate reports on a topic identified below. The reader is referred to the individual SSRC reports. Information on the SSRC reports can be found at www.lsro.org/rrrvw.

I.4.2.1 Exposure Assessment Committee The charge to the Exposure Assessment (EA) Committee was to identify, evaluate, and recommend methods for assessing (1) exposure of smokers, and (2) exposure of individuals to ETS associated with the use of PRRTPs. The EA Committee evaluated smoke chemistry methods and biomarkers of exposure for cigarette smoke and its constituents.

I.4.2.2 Biological Effects Assessment Committee The Biological Effects Assessment (BEA) Committee was charged with identifying and reviewing current state-of-the-science biological methods used to analyze the effects of PRRTP use on individuals who smoke cigarettes and are unlikely to quit. The BEA Committee evaluated current assays, models, and biomarkers that could be used during premarket testing to draw scientific conclusions regarding the comparative risks of PRRTP and conventional cigarettes.

I.4.2.3 Population Effects and Behavior Assessment Committee The Population Effects and Behavior Assessment (PEBA) Committee was charged with identification and evaluation of methods that could be used before and/or after marketing a PRRTP to assess effects on the overall population. Specific effects addressed by the PEBA Committee included altered patterns of initiation (e.g., recruitment of non-smokers, especially adolescents), cessation, and relapse.

I.4.2.4 General approaches used by Committees General approaches and methods used by each Expert Committee included: • Surveying the relevant scientific literature6; • Evaluating additional scientific information provided at committee meetings and/or submitted to LSRO by interested parties; • Applying a weight of evidence approach to the evaluation of the scientific information available on a particular topic; • Recommending the use of various approaches in PRRTP assessments.

6 In general, LSRO did not incorporate information from studies published after September, 2006.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 20 Evaluation of Potential Reduced-Risk Tobacco Products I.5 SELECTION OF DISEASE ENDPOINTS The US Surgeon General currently identifies approximately 35 diseases and conditions as caused by smoking cigarettes (Table I-3) (U.S. Department of Health and Human Services, 2004b). Of these, LSRO identified three for inclusion in an evaluation of the risk-reduction potential of PRRTPs: lung cancer, chronic obstructive pulmonary disease, and cardiovascular disease. These three are responsible for approximately 90% of the total morbidity and mortality resulting from smoking cigarettes (Table I-4) (Centers for Disease Control and Prevention, 2002). Although adverse effects on the fetus are of great importance and concern, LSRO did not include this endpoint because clinical studies of PRRTPs in pregnant women were considered inappropriate.

I.6 SELECTION OF CONTROL PRODUCTS There are two broad categories of control cigarettes: reference cigarettes and commercially available conventional cigarettes.

LSRO recommends that reference cigarettes be included in preclinical studies as an analytical control. Kentucky reference cigarettes are “research standards” for comparing smoke constituent yields within and between laboratories when cigarettes are machine-smoked under identical conditions. They were developed by the National Cancer Institute of the National Institutes of Health, the Agricultural Research Service of the US Department of Agriculture, and the Tobacco Health Research Institute at the University of Kentucky (Davies & Vaught, 1990). Reference cigarettes provide specified cigarette-smoking machine yields of nicotine, tar (defined as total particulate matter minus nicotine and water), and other smoke constituents (Davies & Vaught, 1990).

Conventional cigarettes are commercial cigarettes that incorporate materials and designs typical of those that have been used in cigarette manufacturing for a number of years (Counts et al., 2006).7 Conventional cigarettes fall into three categories based on tar yields when machine-smoked following the FTC protocol: full flavor (regular); full flavor, low tar (light); and ultra-low tar (ultra light). Regular cigarettes produce more than 14.5 mg tar/cigarette; light cigarettes produce between 6.5 and 14.5 mg tar/cigarette, and ultralight cigarettes produce less than 6.5 mg tar/cigarette (Chepiga et al., 2000).

7 Non-conventional cigarettes are commercial cigarettes that incorporate construction designs, material components, and/or technologies that differ to varying degrees from the majority of commercial cigarettes. In this report, products identified as PRRTPs that are intended to be smoked are non-conventional cigarettes.

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Table I-3. Diseases and Other Adverse Health Effects for Which Smoking is Identified as a Cause in the 2004 Surgeon General Reporta

Disease Conclusions from prior Conclusion from Surgeon General Reportsb 2004 Surgeon General Report Cancer Bladder “Smoking is a cause …” (1990) “[E]vidence is sufficient to infer a causal relationship …” Cervical “Smoking has been consistently “[E]vidence is sufficient to infer a associated …” (2001) causal relationship …” Esophageal “Cigarette smoking is a major “[E]vidence is sufficient to infer a cause…” (1982) causal relationship …” Kidney “Cigarette smoking is a “[E]vidence is sufficient to infer a contributory factor …” (1982) causal relationship …” Laryngeal “Cigarette smoking is causally “[E]vidence is sufficient to infer a associated with …” (1980) causal relationship …” Leukemia “Leukemia has recently been “[E]vidence is sufficient to infer a implicated as a smoking related causal relationship …” disease …” (1990) Lung “ … data confirm conclusion of “[E]vidence is sufficient to infer a SG in 1964 and strengthen causal causal relationship …” relationship … in women” (1967) Oral “Cigarette smoking is a major “[E]vidence is sufficient to infer a cause of…” (1982) causal relationship …” Pancreatic “Smoking cessation reduces the “[E]vidence is sufficient to infer a risk of pancreatic cancer…” causal relationship …” (1990) Stomach “Data on smoking and cancer of “[E]vidence is sufficient to infer a the stomach …are unclear” causal relationship …” (2001) Cardiovascular diseases Abdominal aortic “Death from … is more common “[E]vidence is sufficient to infer a aneurysm in smokers …” (1983) causal relationship …” Atherosclerosis “…the most powerful risk factor “[E]vidence is sufficient to infer a …” (1983) causal relationship [with] subclinical atherosclerosis …” Cerebrovascular “Cigarette smoking is a major “[E]vidence is sufficient to infer a disease (stroke) cause …” (1989) causal relationship …” Coronary heart “…smoking is causally related … “[E]vidence is sufficient to infer a disease in men and women” (1979) causal relationship …” Respiratory diseases Chronic “Cigarette smoking is the most “[E]vidence is sufficient to infer a obstructive important of the causes of… and causal relationship …” pulmonary increases the chances of dying disease (COPD) from …” (1964) Pneumonia “Smoking cessation reduces rates “[E]vidence is sufficient to infer a of respiratory symptoms …” causal relationship between (1990) smoking and acute respiratory diseases, including pneumonia …” Respiratory “In utero exposure … is “[E]vidence is sufficient to infer a effects in utero associated with reduced lung causal relationship …” function among infants … ” (2001)

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Table I-3. Diseases and Other Adverse Health Effects for Which Smoking is Identified as a Cause in the 2004 Surgeon General Reporta (continued)

Disease Conclusions from prior Conclusion from Surgeon General Reportsb 2004 Surgeon General Report Respiratory diseases Respiratory “Cigarette smoking during “[E]vidence is sufficient to infer a effects in childhood and adolescence causal relationship between childhood and produces significant health active smoking and impaired lung adolescence problems … [including] potential growth …” retardation in rate of lung growth and the level of maximum lung “[E]vidence is sufficient to infer a function.” (1994) causal relationship … [with] early onset of lung function decline …”

“[E]vidence is sufficient to infer a causal relationship … [with] respiratory symptoms …”

“[E]vidence is sufficient to infer a causal relationship … [with] asthma-related symptoms …” Respiratory “Cigarette smoking accelerates “[E]vidence is sufficient to infer a effects in the age-related decline in lung causal relationship …” adulthood function …. With sustained abstinence … the rate of decline “[E]vidence is sufficient to infer a returns to that of never smokers.” causal relationship between (1990) sustained cessation … and a return of rate of decline … to that of [never smokers]” Other respiratory “Smoking cessation reduces rates “[E]vidence is sufficient to infer a effects of respiratory symptoms … causal relationship between compared with continued active smoking and all major smoking.” (1990) respiratory symptoms among adults …”

“[E]vidence is sufficient to infer a causal relationship between active smoking and poor asthma control.” Reproductive Effects Sudden infant “The risks for perinatal mortality… “[E]vidence is sufficient to infer a death syndrome and … SIDS are increased…” causal relationship between (SIDS) (2001) [SIDS] and maternal smoking during and after pregnancy.” Infertility “… increased risks for conception “[E]vidence is sufficient to infer a delay and … primary and causal relationship … [with] secondary infertility.” (2001) reduced fertility in women.”

Low birth weight, “Infants … have a lower average “[E]vidence is sufficient to infer a fetal growth birth weight … ” (2001) causal relationship … [with] fetal restriction growth restriction and low birth weight.”

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Table I-3. Diseases and Other Adverse Health Effects for Which Smoking is Identified as a Cause in the 2004 Surgeon General Reporta (continued)

Disease Conclusions from prior Conclusion from Surgeon General Reportsb 2004 Surgeon General Report Reproductive Effects Pregnancy “… is associated with increased “[E]vidence is sufficient to infer a complications risks for [pregnancy causal relationship … [with] complications].” (2001) premature rupture of the membranes, placenta previa, and placental abruption.”

“[E]vidence is sufficient to infer a causal relationship … [with] preterm delivery and shortened gestation.” Other effects Cataract “Women … have increased risk “[E]vidence is sufficient to infer a … ” (2001) causal relationship… [with] nuclear cataract.”

Diminished “Relationships…with cough and “[E]vidence is sufficient to infer a health phlegm … are judged to be causal relationship … [with] status/morbidity causal ….” (1984) diminished health status that may be manifest as increased “… the overwhelmingly most absenteeism from work and important cause of cough, chronic increased use of medical care bronchitis, and mucus services.” hypersecretion.” (1984) Hip fractures “Women … have an increased “[E]vidence is sufficient to infer a risk…” (2001) causal relationship …” Low bone “Postmenopausal women…have “In postmenopausal women the density lower bone density …” (2001) evidence is sufficient to infer a causal relationship …” Peptic ulcer “Relationship [with] death rates “[E]vidence is sufficient to infer a disease from peptic ulcer, especially causal relationship … [with] peptic gastric ulcer, is confirmed. … ulcer disease in people who are morbidity data suggest a similar Heliobacter pylori positive.” relationship with prevalence ….” (1967)

aAdapted from Table 1.1 (U.S. Department of Health and Human Services, 2004b). bYear of cited Surgeon General Report is given in parenthesis.

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Table I-4. Risks of the Three Most Common Causes of Death in Smokersa

Disease Number of deaths/year Increased risk for smokers compared due to smokinga to non-smokersb LC 123,836 ~20 (16–25) times more likely to die COPD 90,582 ~10–20 (7–17) times more likely to die CVD 137,979 ~2 (1.4–1.8) times more likely to die

aDuring 1997–2001(Centers for Disease Control and Prevention, 2005c); b(Thun et al., 1997). COPD: chronic obstructive pulmonary disease; CVD: cardiovascular disease; LC: lung cancer

Conventional cigarettes from at least two different tar categories that are representative of the contemporary market should be used as controls for preclinical and clinical studies. The selection of specific control cigarettes should be based on study design and goals (e.g., researchers may want to use each subject’s brand of cigarette as the control product). Conventional cigarettes and PRRTPs should be tested concurrently.

I.7 AREAS OF INITIAL CONSENSUS At the outset of the RRRP, LSRO established the following areas of consensus: • Tobacco use is the major cause of preventable death and disease in the US; • The best approach to tobacco is to abstain (i.e., never start); • The best action for those who smoke (or use other types of tobacco) is to quit immediately; • Many smokers will not or can not quit permanently, and some adolescents will begin to smoke no matter what information is provided or obstacles introduced; and • A tobacco product that reduces disease risk in smokers might be beneficial for some subpopulations of smokers.

I.8 REPORT ORGANIZATION Chapters II and III of this report include reviews of preclinical and clinical test methods, respectively, for the evaluation of individual risk reduction. In Chapter IV, an approach for preclinical and clinical data assessment to reach conclusions concerning the likelihood that a PRRTP will reduce individual risk is presented. Methods to evaluate effects of a PRRTP on population risk are discussed in Chapter V. Finally, the interplay of scientific findings and policy considerations in decision making for PRRTPs is described in Chapter VI.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. PRECLINICALII STUDIES

II.1 INTRODUCTION

II.2 PRODUCT CHARACTERISTICS

II.3 CHEMISTRY II.3.1 Mainstream Smoke II.3.1.1 Selection of cigarette smoking machine methods II.3.1.2 Selection of smoke analytes II.3.1.3 Selection of analytical methods II.3.1.4 Evaluation of particulate matter II.3.2 Environmental Tobacco Smoke

II.4 CYTOTOXICITY AND GENOTOXICITY ASSAYS

II.5 ANIMAL STUDIES II.5.1 Study Selection and Design II.5.2 Animal Models of Human Disease

II.6 CONCLUSIONS AND RECOMMENDATIONS

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 26 Evaluation of Potential Reduced-Risk Tobacco Products PRECLINICALII STUDIES II.1 INTRODUCTION This chapter addresses preclinical analyses, including product characterization, chemistry, cytotoxicity and genotoxicity assays, and animal studies. Preclinical studies are used to identify any biologically and statistically significant differences that may indicate a potential for altered exposure and risk in individuals using a potential reduced-risk tobacco product (PRRTP) compared to individuals using conventional cigarettes.

PRRTPs that show a potential to reduce exposure and risk in valid preclinical tests can proceed to clinical studies. PRRTPs that show a potential for increasing exposure and risk should not be tested in clinical studies; they should either be redesigned and retested or be rejected for use as a PRRTP. Additional details on preclinical studies and the rationale for Life Sciences Research Office (LSRO) conclusions and recommendations presented in this chapter will be available in separate LSRO reports on exposure assessment and biological effects assessment.

II.2 PRODUCT CHARACTERISTICS A PRRTP that is intended to be smoked is likely to be modified to reduce the amounts of toxic substances in cigarette smoke. Such modifications include changes in cigarette composition, design, and engineering (World Health Organization, 2003). Investigators should consider the differences in the physical and chemical characteristics between the PRRTP and control cigarettes when developing PRRTP testing approaches. Table II-1 provides examples of product modifications and identifies chemical analyses that should be conducted as a component of overall characterization of PRRTP smoke.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Preclinical Studies 27 Identify new PRRTP filter components and determine whether they transfer into smoke or change pyrolysis product compared to control compared to control cigarette smoke Determine whether ingredients transfer into smoke or change pyrolysis products compared to control; measure pyrolysis and combustion products of the ingredient(s) Identify new PRRTP components and determine if they transfer into smoke or if emissions differ from conventional cigarettes; characterize PRRTP smoke to determine pyrolysis and combustion product level increases or decreases compared to levels in control cigarette smoke

: potential reduced-risk tobacco product : Product Modification Tobacco mostly heated instead of burned to reduce toxic products of combustion tobacco modified of Inclusion Chemical Analyses Addition of ingredients to decrease levels selected toxicant Identify new constituents in PRRTP smoke Inclusion of a filter designed to reduce specific smoke constituents Table II-1. Examples of PRRTP Modifications and Associated Chemical Analyses Examples of PRRTP II-1. Table PRRTP

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 28 Evaluation of Potential Reduced-Risk Tobacco Products II.3 CHEMISTRY II.3.1 Mainstream Smoke Mainstream smoke (MS) is smoke drawn from the butt end of a cigarette into the mouth, as a smoker puffs on a cigarette. Mainstream smoke from the PRRTP and control cigarette should be analyzed to compare constituent yields on a per-cigarette basis from the PRRTP to those from control cigarettes. These smoke chemistry studies should be accurate, detailed, and sufficiently broad to measure any differences in smoke constituent yields, and results should guide subsequent PRRTP testing. Appropriate statistical analyses should be conducted.

II.3.1.1 Selection of cigarette smoking machine methods Smoke constituent yields are influenced by product characteristics and by how the cigarette is smoked (Counts et al., 2005). Machine-generated smoke studies are used to assess constituent yields under standard conditions, however, machine-based methods cannot be used to estimate exposure of individual smoker or population of smokers because of variations in intra- and inter-individual smoking behavior (Federal Trade Commission, 1967b). Table II-2 summarizes current standards for machine generation of smoke.

Selection of smoking machine methods to assess PRRTPs is critical because alternative smoking regimens produce very different smoke measurements [e.g., total particulate matter (TPM)] and different amounts and types of individual smoke constituents (Counts et al., 2005; Dixon & Borgerding, 2006). Given differences in the ‘microenvironment’ of the burning cigarette and the relative contributions from smoke-formation mechanisms (e.g., combustion, pyrolysis, pyrosynthesis) when cigarettes are smoked with different puffing parameters and vent-blocking conditions, the chemical composition of mainstream smoke generated by different smoking machine protocols is significantly different (Dixon & Borgerding, 2006). These differences, however, do not necessarily correlate with increased machine- smoking intensity.

Cigarette smoke constituent yields typically increase as ‘intensity’ of the smoking method increases (Counts et al., 2005; Dixon & Borgerding, 2006); however, constituent yields do not necessarily increase in proportion to increases in tar and nicotine yields. Some analytes show decreases in concentration expressed on a per-mg-tar or per-mg-nicotine basis, while other analytes show increases. Furthermore, changes in constituent concentrations do not occur to the same extent for all cigarettes (Dixon & Borgerding, 2006). The fact that the tobacco blend of a cigarette is a critical

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Preclinical Studies 29 Federally mandated cigarette-smoking method. Recommended for assessment of all PRRTPs State-mandated method Not representative of breadth human smoke exposure Yields underestimate smokers’ intake when smoking reduced-yield products Not representative of breadth human smoke exposure 67; this 9 FTC adopted the method in 1 method has the greatest amount of historical data Provides information on emissions associated with more intense smoking

35 ml 2 sec 60 sec None To 23 mm or to the length of the filter and overwrap + 3 mm 45 ml 2 sec 30 sec 50% Puff volume Puff duration Inter-puff interval Filter vent blocking Butt length Description of Method Strengths Weaknesses Comments Puff volume Puff duration Inter-puff interval Filter vent blocking 8 99 80b) 9 8) 7; in Texas, 1 67a,b; 1 99 9 99 Method introduced in Massachusetts, 1 Rationale for Method Developed to measure yields of ‘tar,’ nicotine, and, later, carbon monoxide in MS generated under standard and reproducible conditions (Federal Trade Commission, 1 Intended to predict the nicotine intake for the average smoker (Massachusetts Department of Public Health, 2005; Texas Administrative Code, 1

Cigarette Smoking Machine Method FTC Commonwealth of Massachusetts/ State of Texas Table II-2. Cigarette-Smoking Machine Methods II-2. Table

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 30 Evaluation of Potential Reduced-Risk Tobacco Products , e.g. Mandated by the Canadian Federal Government for all cigarettes sold in Canada May be useful for PRRTPs that are significantly different from conventional cigarettes ( Accord® can only yield eight puffs/cigarette)

Not representative of breadth human smoke exposure Not representative of breadth human smoke exposure

Provides information on emissions associated with more intense smoking Provides information under actual smoking conditions )

: potential reduced-risk tobacco product :

continued 55 ml 2 sec 30 sec 100% PRRTP Puff volume Puff duration Inter-puff interval Percent of filter vents blocked Puff volume, puff duration, inter-puff interval are measured for the smoker and used as cigarette smoking-machine settings : mainstream smoke, mainstream smoke, :

MS 8) 99 Rationale for Method for Rationale Description of Method Strengths Intended to “provide Weaknesses data that reflects the emissions that are Comments actually available to the consumer” (Health Canada & Losos, 1 Measures the puff profile of an individual smoker : Federal Trade Commission, Trade Federal :

Cigarette Smoking Machine Method Canadian Federal Government Method Based on Topography Studies FTC Table II-2. Cigarette-Smoking Machine Methods ( Cigarette-Smoking Machine II-2. Table

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determinant of test results underscores the importance of using an appropriate control product. Different smoking regimens and tobacco blends also affect results in genotoxicity and cytotoxicity studies: as smoking intensity increases, mutagenicity decreases, while cytotoxicity increases (Dixon & Borgerding, 2006).

Based on its review, LSRO recommends use of at least two methods to generate smoke for all evaluations, one of which should be the Federal Trade Commission (FTC) method, which has the most historical data and can serve as an analytical control (Federal Trade Commission, 1967a,b). The use of at least two smoke generation methods will provide information on the effect of variations in puffing behavior on smoke composition. Selection of additional smoke generation methods should be informed by PRRTP and control product characteristics. Smoking topography data can be used to develop cigarette-smoking machine protocols that match use behaviors for the PRRTP and control product (Djordjevic et al., 2000).

II.3.1.2 Selection of smoke analytes Fresh MS contains over 4,700 constituents (Baker, 1999; Dube & Green, 1982; Roberts, 1988), some of which have been categorized as toxic to humans (International Agency for Research on Cancer, 2004a; Smith et al., 1997; 2000a,b).

Different lists of smoke toxins (e.g., the widely used “Hoffmann Analytes” [Hoffmann & Hoffmann, 1997, 1998]) in the scientific literature are often used to guide smoke analyte selection based on the potential health risk of each to smokers (Hoffmann & Hoffmann, 1998, 2001; Rodgman & Green, 2002; Smith et al., 1997; U.S. Consumer Product Safety Commission, 1993; U.S. Department of Health, Education, and Welfare, 1964; World Health Organization, 1986). Because the specific chemicals or classes of chemicals responsible for adverse health effects associated with smoking conventional cigarettes are incompletely characterized (Rodgman & Green, 2002), the degree to which these lists bear any relation to disease outcomes is unclear. As a result, LSRO recommends conducting broad analytical screens of cigarette smoke; these screens should measure as many smoke constituents in both gas and particulate phases of smoke as possible. LSRO recommends that surrogate chemicals not be used to reflect changes in entire classes of chemicals.

LSRO recommends that additional chemical analyses be performed on individual smoke constituents based on the results of the broad analytical screen, changes in product characteristics (e.g., new added ingredients),

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changes in tobacco characteristics (e.g., genetically altered to produce lower levels of nitrosamines), or product design features (e.g., filters containing new materials).

Differences expected between smoke constituent yields for the PRRTP and control products and the reasons for expecting these differences should be included in the rationale provided for the selection of specific analytes for further study. The rationale for inclusion/exclusion of particular analytes may include: (1) availability of validated analytical methods; (2) evidence for carcinogenic or other toxic properties (e.g., from sources such as International Agency for Research on Cancer, National Toxicology Program, and/or US Environmental Protection Agency); and (3) availability of suitable analytical quantification methods (Rodgman & Green, 2002).

If substances not previously detected in smoke from cigarettes or if increases in known smoke constituents are found in smoke from the PRRTP, the following steps are recommended: (1) determine/confirm the identity of the substance; (2) measure levels of the substance in smoke; (3) consult toxicological information if available, including structure-activity relationships (SAR)8 and quantitative SAR (QSAR)9; and (4) based on the information developed in the preceding steps, determine whether the substances are likely to be of biological concern. Substances likely to be of biological concern should be investigated further.

II.3.1.3 Selection of analytical methods Standard analytical methods can be used to determine whether differences in smoke constituent yields indicate “real” yield differences. There are standard methods for determining tar, nicotine, and carbon monoxide levels in smoke (International Organization for Standardization, 1995, 1997, 2000a,b). Standard methods for measuring other tobacco smoke constituents are limited to benzo[a]pyrene and tobacco-specific nitrosamines in MS (CORESTA, 2004, 2005).

Although the use of standard methods is preferred, LSRO concluded that appropriate validated methods are also appropriate to compare yields of substances in smoke (when smoke from PRRTPs and control cigarettes are generated using the same protocol). The selection rationale for validated analytical methods should be provided and the validation process (including

8Structure-activity relationships refer to the likelihood that chemicals with similar molecular structures are likely to have similar toxicological effects. 9 QSAR are mathematical relationships linking chemical structure and toxicological activity.

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intra- and inter-laboratory studies) should be described in detail. Descriptions of methods should be made widely available, preferably through publication in peer-reviewed journals. In addition, such information could be posted on the Internet for wider access and review.

LSRO encourages further development and validation of newer analytical methods and recommends their inclusion in testing approaches. Examples of promising approaches include methods that characterize smoke chemistry in near-real time and/or have higher throughput as well as techniques that allow for more detailed analyses (Adam et al., 2006; Mitschke et al., 2005).

II.3.1.4 Evaluation of particulate matter Smokers are potentially exposed to particles from cigarettes (e.g., hardened adhesives); flakes of packaging and cigarette tipping inks; hardened casings; fibers from cigarette papers and cigarette packs; and tobacco fines, such as stem fibers, lamina, and reconstituted tobacco (Agyei-Aye et al., 2004). TPM from the PRRTP and control cigarettes should be measured and characterized, and the potential for exposure to TPM components should be determined.

II.3.2 Environmental Tobacco Smoke In addition to MS, cigarette smoking produces environmental tobacco smoke (ETS), also known as secondhand smoke. ETS is a mixture of 10–20% exhaled MS and 80–90% diluted sidestream smoke (SS) that is released from the lit end of the cigarette (Baker & Proctor, 1990). As SS and exhaled MS diffuse and move away from the source, they are diluted and undergo various physical and chemical changes (Baker & Proctor, 1990).

Since ETS primarily consists of SS, analysis of SS chemistry will provide information about ETS chemistry. Methods for SS and ETS chemistry analyses (e.g., chamber studies) are available (Adlkofer et al., 1990; Jaakkola & Jaakkola, 1997). Nicotine, which is primarily present in the vapor phase in SS/ETS (in MS it is primarily present in the particulate phase) is currently the most useful specific chemical marker for ETS (Baker & Proctor, 1990). The chemistry of SS and/or ETS from a PRRTP should be compared to that from control cigarettes to identify any important differences in quantity of smoke constituents. Differences should be further investigated if an ETS claim is being considered or if PRRTP emissions show an increase in levels of one or more ETS constituents or new constituents are detected.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 34 Evaluation of Potential Reduced-Risk Tobacco Products II.4 CYOTOXICITY AND GENOTOXICITY ASSAYS Cytotoxicity and genotoxicity assays are integral components of toxicological assessments and are accepted by regulatory authorities as methods to evaluate potential biological activity. These tests are rapid and inexpensive, have a long history of use, and provide a quantitative evaluation of toxicity. Cytotoxicity and genotoxicity assays are used worldwide, and international guidelines have been published by the International Conference on Harmonisation (ICH)10 (International Conference on Harmonisation Steering Committee, 1995, 1997b). Because a single assay can not provide toxicity information for all agents, the ICH recommends using a battery of these tests.

International Conference on Harmonisation Recommendations for a Test Battery A core battery of cytotoxicity and genotoxicity studies has been accepted by industry and regulators through the ICH consultative process (International Conference on Harmonisation Steering Committee, 1995, 1997b). ICH recommends that a test battery include: • A test for gene mutation in bacteria; • An in vitro test with cytogenetic evaluation of chromosomal damage using mammalian cells or an in vitro mouse lymphoma tk+/- assay; and • An in vivo test for chromosomal damage using rodent hematopoietic cells.

Based on its review of cytotoxicity and genotoxicity assays and recommendations like that of the ICH, LSRO concluded that the test battery presented in Table II-3 should be used to compare biological effects of PRRTPs and controls.

LSRO selected this test battery for the evaluation of PRRTPs based on: • The merits of the individual assays; • Test battery guidelines of the ICH (International Conference on Harmonisation Steering Committee, 1995, 1997b) and U.S. Food and Drug Administration (2001); and

10 The International Conference on Harmonisation is one many organizations that has developed guidelines for validating analytical methodology.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Preclinical Studies 35 , 2000; et al. 8, 2001; , 2002) 99 , 1 et al. et al. chromosomal interchanges, e.g., DNA strand breaks, large chromosomal deletions) Hagmar Smerhovsky Cannot identify nongenotoxic carcinogens or substances that are mutagenic by other mechanisms ( Effects of metabolic products are not well modeled Findings have been contradictory regarding a link between micronuclei frequency and increased human cancer risk (Bonassi Does not provide direct information on the mutagenic or carcinogenic potency of a substance in mammals Does not provide direct information on the mutagenic or carcinogenic potency of a substance in humans , et al. 8) 8) 99 99 , 1 , 1 are carcinogenic et al. et al. ) 0) 999 99 1 Highly reproducible results for TPM (variation <10%) (Roemer Sensitive enough to differentiate cigarette modifications (Tewes Accepted by regulatory agencies (U.S. Food and Drug Administration, 2001) Long history of use Rapid and economical Exposure to fresh whole smoke can be evaluated (Massey Faster; requires less technical skill than scoring of chromosomal aberrations Reliably measures chromosome damage/loss High percentage of chemicals mutagenic in Salmonella in rodents (Shelby & Zeiger, 1

i.e., chromosome breaks, e.g., Often used as a screening tool to assess a chemicals carcinogenic potential Identifies substances that cause cytogenetic damage ( structurally abnormal chromosomes, spindle abnormalities); this damage results in the formation of micronuclei containing lagging chromosome fragments or whole chromosomes Identifies chemicals that induce point mutations ( substitution, addition, or deletion of one or more DNA base pairs). Reversion of mutations in the tester strains restores bacteria ability to synthesize an essential amino acid and grow on selected media

micronucleus Test Purpose Salmonella Strengths Weaknesses mutagenicity assay In vitro assay Table II-3. Cytotoxicity and Genotoxicity Assays and Genotoxicity Cytotoxicity II-3. Table

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 36 Evaluation of Potential Reduced-Risk Tobacco Products Does not provide direct information on the mutagenic or carcinogenic potency of a substance in humans Relevance to specific human disease endpoints is questionable et 7b,c; 99 8) ) metabolism, , 1 99 assay et al. in vivo 7a,c; 1 in vitro 99 8) continued , 1 99 1 Can further investigate a mutagenic effect detected by an Rodents can be exposed to whole smoke Exposure to fresh whole smoke can be evaluated (Bombick Sensitive enough to differentiate cigarette modifications (Bombick al. Reflects pharmacokinetics, and DNA repair processes Sensitive, quantitative, and reproducible : total particulate matter : TPM Detect changes in chromosomal integrity by measuring chromosomal aberrations in rodent bone marrow cells or immature erythrocytes in the peripheral blood Indicates acute toxicity Measures cell membrane integrity, cell survival, and cell viability (Andreoli, 2003) assays for Chromosome aberration Sister chromatid exchange Micronucleus Lactate dehydrogenase release : deoxyribonucleic acid; acid; deoxyribonucleic : Weaknesses Test Purpose Strengths In vivo chromosomal damage Cytotoxicity assay Table II-3. Cytotoxicity and Genotoxicity Assays ( Assays and Genotoxicity Cytotoxicity II-3. Table DNA

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• Centre de Coopération pour les Recherches Scientifiques Relatives au Tabac (CORESTA) recommendations for testing tobacco smoke toxicity (Doolittle & Massey, 2003).

Several issues should be considered when conducting cytotoxicity and genotoxicity tests to evaluate PRRTPs: • All assays should include appropriate controls (e.g., Kentucky reference and conventional cigarettes); • Assays should permit measurement of effects of whole smoke and the particulate and vapor phases of smoke; • Because different smoking machine methods and tobacco blends affect the results of genotoxicity and cytotoxicity studies (Dixon & Borgerding, 2006), the FTC method and at least one other method for smoke generation should be included and the tobacco blends in PRRTPs and controls should be fully documented; • Smoke exposure should be quantified using standardized measures to allow comparison of results from different studies. Approaches to attain a standard measure include: normalization to TPM, standardization based on nicotine delivery, and/or use of a minimal toxic dose to identify a reliable dose-response curve; and • Studies should be conducted in compliance with Good Laboratory Practice guidelines (U.S. Department of Health, Education, and Welfare, 1978).

II.5 ANIMAL STUDIES LSRO recommends using conventional animal toxicity studies (National Toxicology Program, 1996, 2006; U.S. Department of Health, Education, and Welfare, 1980) to assess PRRTPs. Conventional animal toxicity studies used previously to evaluate cigarettes and PRRTPs are presented in Table II-4.

II.5.1 Study Selection and Design Organizations have established minimum standards for the design, conduct, and analysis of animal studies (International Conference on Harmonisation Steering Committee, 1994, 1997a; Organization for Economic Cooperation and Development 1981a,b); these standards should be followed in studying a PRRTP. It is critical to determine the actual exposure of animals to smoke; the failure to adequately address exposure is a serious shortcoming in many published studies.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 38 Evaluation of Potential Reduced-Risk Tobacco Products Very short duration; does not provide adequate information about chronic exposures Provides general toxicology but not disease-specific information Assists in setting doses and other design considerations for the 13-wk exposure study Extensive history of use (National Toxicology Program, 2006) Provides basis for determining treatments for each strain and species to be used in a 2-year toxicology study Extensive history of use (National Toxicology Program, 2006) Provides toxicological data Provides a basis to identify potential target organs and toxicities , , , et et al. et al. et al. 2) 99 , 1 0) 3) 2a) , 2001) 99 99 99 Clinical pathology Clinical pathology Histopathology (Coggins et al. DNA adducts Alveolar macrophage cytogenetics (Lee Histopathology (Ayres al. Sister chromatid exchange, chromosome aberration, micronuclei in bone marrow (Lee 1 DNA adducts Alveolar macrophage cytogenetics (Lee 1 1 81b) 9 81a) 9 Sprague-Dawley rats Sprague-Dawley rats Exposure to cigarette smoke (nose- only) or sham-exposure to filtered air 6 hr/day for 14 days Monitoring of chamber atmospheres for particulate TPM and vapor CO phase concentrations Analysis of: blood for COHb; plasma for nicotine and cotinine Design and conduct of studies according to OECD guidelines (1 Exposure to cigarette smoke (nose- only) or sham-exposure to filtered air 1–6 hr/day, 5–7 days/wk 13 consecutive wks (conditions study- dependent). Monitor chamber atmospheres for TPM and CO phase concentrations Analyze blood for COHb; plasma nicotine and cotinine Design and conduct studies per OECD guidelines (1 Test Protocol 14-day inhalation Strengths Endpoint(s) Weaknesses 13-week inhalation

Table II-4. Animal Study Types Commonly Used to Assess Cigarettes Commonly Types Animal Study II-4. Table

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Preclinical Studies 39 : OECD Inhalation, not topical, exposure is major human route Only tests particulate phase of smoke 80) ) 9 : deoxyribonucleic acid; deoxyribonucleic acid; : DNA 6; U.S. continued 99 Department of Health, Education, and Welfare, 1 Reproducible; extensive history of use (National Toxicology Program, 1 Good dose response for TPM concentration and number of mice with masses and total number of masses/dose group

2b) 99 , 1 : total particulate : matter et al. , 2004a,b) : 7,12-dimethylbenz(a)anthracene; 7,12-dimethylbenz(a)anthracene; : TPM DNA adduct formation (Lee Skin pathology Clinical pathology Histopathology (Meckley et al. DMBA weeks (Meckley 9 : carboxyhemoglobin: carboxyhemoglobin: :

COHb , 2004a,b) Initiation Starting one week later, 0, 10, 20, or 40 mg TPM dermally applied 3 times/week for 2 et al. Shaved dorsal surfaces of 4–6- week-old female SENCAR mice treated with single dose of DMBA Promotion : carbon monoxide; carbon monoxide; : Test Protocol Strengths Endpoint(s) Weaknesses Dermal tumor promotion

Table II-4. Animal Study Types Commonly Used to Assess Cigarettes ( Commonly Types Animal Study II-4. Table CO Organization for Economic Cooperation and Development; and Development; Economic Cooperation Organization for

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LSRO recommends using the following approaches to attain standard exposures that will allow intra- and inter-study comparisons: • Use experimental exposures that simulate smoker exposures (i.e., MS exposure levels reflecting various pack/day habits); • Characterize smoke inhaled by animals, by including information on cigarette type, smoking machine, smoking protocol, and other relevant details that could affect inter-study comparability of exposures; • Provide sufficient detail regarding exposure protocols and equipment; and • Use biomarkers to confirm actual internal exposure (dose) to smoke constituents in test and control animals. Examples of internal exposure biomarkers include carboxyhemoglobin, nicotine or cotinine, urinary mutagens/carcinogens, and DNA and protein adducts. Carboxyhemoglobin can be used as a biomarker for the gas phase of cigarette smoke, and nicotine or cotinine can be used as biomarkers for the particulate phase. The selection of biomarkers should reflect the chemical characteristics of the test material, and a rationale for selection should be provided.

Additional details about animal exposures can be found in the LSRO report on biological effects assessment (Life Sciences Research Office, 2007a).

II.5.2 Animal Models of Human Disease There are a number of animal models for lung cancer, chronic obstructive pulmonary disease, and cardiovascular disease; strengths and weaknesses associated with each are presented in Table II-5. Because of the potential increased relevance to human diseases associated with smoking (compared to standard toxicological testing), LSRO recommends that the models listed in Table II-5 be incorporated into the PRRTP evaluation process as each model is validated by additional laboratories.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Preclinical Studies 41 model 1 Dose-response not yet established High number of animals required for each study High number of animals required for each study Exposure-related increases are moderate at best and less than seen in B6C3F Shallow dose-response curve may result in inability to detect the small response differences likely to be exhibited by PRRTP Predominantly SS compositions may not accurately reflect human smoker exposures Lacks independent laboratory validation Lacks independent laboratory validation Only shows a small increase in benign lung tumors in a highly susceptible mouse strain Incidence of lung neoplasms was statistically significant for high-dose females Relatively simple and inexpensive method to induce lung tumors with cigarette smoke in a short time period Highest number of cigarette smoke- induced lung adenomas reported for any published rodent study to-date (results were statistically significant) Some dose-response data available Methodology described in detail Can be performed in small laboratories with limited equipment , et al. , 2005) mouse 1 et al. Animal model Strengths Weaknesses 2004) Disease association: LC B6C3F F344 rat inhalation (Mauderly A/J mouse inhalation (Witschi, 2005a,b) inhalation (Hutt Table II-5 Disease-Specific Animal Models Table

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 42 Evaluation of Potential Reduced-Risk Tobacco Products , et al. , 2004) et al -antitrypsin-deficient humans) 1 ; Guerassimov 999 rather than centrilobular lung enlargement (seen in human smokers) Lacks the inflammatory component found in human disease Poor characterization of airway pathology and mucus production changes in published studies makes evaluation of the model difficult 1 Animals must be chosen carefully: Rodents have differing susceptibilities to cigarette smoke-induced emphysema; mice more susceptible than rats; and there are strain-dependent differences (March Considerable time and exposure technology required Often produces panacinar lung enlargement (seen in Model is not currently well defined Lack of standard pathologic and physiologic analyses in published studies makes evaluation of the model difficult , ) et al. ) continued 9 8 9 , 1 et al. 82; Mauderly 9 Produces inflammation of the lung parenchyma Limited studies have produced physiologic changes resembling those in humans with emphysema (Damon 1 Exposure induced mucus metaplasia, mucus cell hyperplasia, and epithelial hypertrophy in rats limited studies Exposure method more relevant than protease-induction for evaluating emphysema risk caused by PRRTP , , et al. et al. Animal model Strengths Weaknesses 2006) 2000) Disease association: COPD Cigarette smoke- induced emphysema (March Protease-induced emphysema (March Cigarette smoke- induced bronchitis (Nikula & Green, 2000) Table II-5. Disease-Specific Animal Models ( II-5. Table

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Preclinical Studies 43 : potential reduced-risk tobacco : PRRTP : lung cancer; lung cancer; : Dose-response not yet established Limited data available; few animals used in the initial study (10 exposed, 10 controls) SS exposure may not accurately reflect human smoker exposures Dose-response not yet established Nonstandard smoke exposure-reporting methods Limited data available; few animals used in the initial study (16 exposed, 16 controls) Lacks independent laboratory validation LC )

continued : cardiovascular disease; disease; cardiovascular : CVD Small animal size permits good quantification of the lesion size and use enough animals to provide statistically robust data ApoE–/– mice have a defined genetic background Short exposure time allows rapid results Short exposure time allows rapid results Lacks independent laboratory validation , , et al. et al. : sidestream smoke : SS : chronic obstructive pulmonary disease; chronic obstructive pulmonary disease; : /SvEv mice 9 Animal model Strengths Weaknesses Disease association: CVD Atherosclerotic plaque formation in ApoE–/– mice (Gairola 2001) Elastase-induced abdominal aortic aneurysm in 12 (Buckley 2004) COPD product; Table II-5. Disease-Specific Animal Models ( II-5. Table

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 44 Evaluation of Potential Reduced-Risk Tobacco Products II.6 CONCLUSIONS AND RECOMMENDATIONS LSRO has concluded that properly conducted preclinical studies will provide useful information to help guide further development and testing of PRRTPs. Preclinical data can be used with clinical study findings in the overall assessment of PRRTPs.

Data from chemical studies will provide the first indication of whether a PRRTP may reduce exposure to smoke constituents. Recommendations for chemical studies include: • Use at least two methods to generate smoke for all evaluations, one of which should be the FTC method (Federal Trade Commission, 1967a,b); • Conduct broad analytical screens that measure as many smoke constituents in both gas and particulate phases of smoke as possible; • Do not limit selection of analytes to those on established lists of toxicants in cigarette smoke; • Do not use surrogate chemicals to reflect changes in entire chemical classes; • Use standard methods for individual constituents, if available; and • Use well-described non-standard methods when standard methods are not available.

Data from cytotoxicity and genotoxicity assays will provide the first indication of whether a PRRTP may reduce adverse biological effects. Based on its review of these tests and recommendations like those of the ICH, LSRO recommends that the test battery presented in Table II-3 be used to compare the genotoxic and cytotoxic effects of PRRTPs and controls.

Standard animal toxicology studies (i.e., acute, subchronic, and chronic) can also be used to compare the toxicity of a PRRTP with that of a conventional tobacco product. LSRO recommends using standard animal toxicity studies (National Toxicology Program, 1996, 2006; U.S. Department of Health, Education, and Welfare, 1980) to assess PRRTPs. Confidence in findings from animal studies will increase when consistent effects for similar study designs are observed in at least two animal species.

Validated animal models of disease provide the most relevant preclinical data on the potential of a PRRTP to reduce the risks associated with smoking. LSRO recommends incorporating the animal models listed in Table II-5 into the PRRTP evaluation process as each model receives additional, independent validation.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. CLINICALIII STUDIES

III.1 INTRODUCTION III.1.1 Biomarkers III.1.2 Clinical Study Design

III.2 CLINICAL STUDIES OF EXPOSURE III.2.1 Biomarkers of Exposure III.2.2 Smoking Topography III.2.3 Other Measures of Exposure III.2.4 Interpretation of Exposure Study Results

III.3 CLINICAL STUDIES OF EFFECT III.3.1 Biomarkers of Effect III.3.1.1 Lung cancer biomarkers III.3.1.2 Pulmonary disease biomarkers III.3.1.3 Cardiovascular disease biomarkers III.3.2 Selection of Biomarkers of Effect

III.4 CONCLUSIONS AND RECOMMENDATIONS

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 46 Evaluation of Potential Reduced-Risk Tobacco Products CLINICALIII STUDIES III.1 INTRODUCTION Clinical studies described in this chapter are intended to determine whether, compared to smoking conventional cigarettes, (1) exposure to toxic constituents is reduced and (2) biological effects seen when using potential reduced-risk tobacco products (PRRTP) are indicative of reduced risk.

Additional detail on clinical studies and the rationale for Life Sciences Research Office (LSRO) conclusions and recommendations presented in this chapter are available in LSRO reports on exposure assessment and biological effects assessment (Life Sciences Research Office 2007a,b).

III.1.1 Biomarkers After reviewing methods to assess exposure and biological effects, LSRO has concluded that the most reliable and relevant approach for the premarket assessment of exposure and health effects of PRRTPs in humans is to measure changes in biomarkers of exposure for cigarette smoke and biomarkers of effect for diseases associated with smoking conventional cigarettes.

LSRO adapted the following definitions from those used by the National Research Council (Committee on Biological Markers of the National Research Council, 1987), the Institute of Medicine (2001) and Hatsukami et al. (2006): • A “biomarker of exposure” is a constituent or metabolite that is measured in a biological fluid or tissue or that is measured after it has interacted with critical subcellular, cellular, or target tissues. • A “biomarker of effect” is a measured effect including early subclinical biological effects; alterations in morphology, structure, or function; or clinical symptoms consistent with the development of health impairment and disease.

The relationship of these categories of biomarkers to exposure, biological effects, and disease is depicted in Figure III.1. An analogous system to quantify human exposure to radiation and the resulting biological effects is well established and in use (Rubin et al., 2005).

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Clinical Studies 47 nal (harm) Disease Outcome function morphology, structure, and Alterations in Effect Biomarkers of . Copyright 1989 by the National Academy of Sciences, the National Academy Copyright 1989 by . effects Early biological Biologically effective dose

Biologic Markers in Reproductive Toxicology in Reproductive Biologic Markers Biomarkers of Exposure Internal dose Biomarkers of exposure and effect. Broken lines indicate that the biomarkers used may or may not be directly related to the fi or may lines indicate that the biomarkers used may Broken and effect. Biomarkers of exposure External External exposure Exposure Figure III.1 disease or condition. Adapted and reprinted with permission from courtesy of the National Academies Press, Washington, DC. courtesyWashington, of the National Academies Press,

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III.1.2 Clinical Study Design The preclinical studies described in the previous chapter will provide initial information about the risk-reduction potential of a PRRTP and should guide the design strategy for clinical studies.

Considerations relevant to clinical studies of PRRTPs include: Ethics • Smoking cessation assistance should be offered to study participants before enrollment and after each study; • Members of populations with limited choice should not participate in studies, especially those who may be influenced by the sponsor or investigator; • Nonsmokers and minors (younger than 18) should not participate in studies that require them to smoke conventional cigarettes or use PRRTPs; and • Appropriate Institutional Review Board approvals should be obtained.

Study Population • A range of smokers (e.g., heavy and light smokers, smokers of high- tar and low-tar cigarettes, and smokers of various ages and smoking durations) should be included; • Participants should be representative of smokers with characteristics of potential PRRTP users (e.g., gender, ethnicity, physical and mental health status, current medication, occupation, nicotine dependence, and other relevant characteristics); • A sufficient number of participants should be enrolled to achieve the statistical power necessary to meet study goals; and • Participant randomization and investigator blinding methods should be used when possible.

Study Duration • Study duration and stopping rules should be clearly articulated prior to study commencement; • Adequate time to stabilize smoking behaviors should be provided, especially between the arms of crossover studies; and • Duration should be sufficient to see significant changes in biomarkers of interest.

Comparison/Control Groups • Appropriate comparisons should be used, including: o Use of own brand as control;

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o Use of a single control product independent of participants’ usual brand; and o Abstinence with or without nicotine replacement therapy.

Use Characterization • Appropriate biomarkers of exposure (e.g., carbon monoxide and nicotine and its five major metabolites) should be measured, and • Adequate methods to track the quantity of cigarettes smoked should be included (e.g., cigarette butt counting).

Study Design and Conduct • Use a crossover study design in which each individual serves as his/her control to minimize inter-individual variation in smoking behavior/topography (Senn, 2002). • Human studies should be designed and conducted, and data should be reported, according to Good Clinical Practice guidelines (U.S. Food and Drug Administration, 1996); and • Appropriate statistical analyses should be performed (European Parliament, 2001; Henningfield & Keenan, 1993; International Conference on Harmonisation, 1996, 1997, 1998, 2000).

III.2 CLINICAL STUDIES OF EXPOSURE LSRO reviewed approaches to assess exposure to cigarette smoke, such as number of cigarettes smoked per day, cigarette filter analysis, smoking topography studies, and biomarker studies.

LSRO concluded that studies of biomarkers of exposure should be the primary source for exposure data. The advantage of measuring biomarkers is that they reflect the integration of factors that determine internal exposure to tobacco product and smoke constituents, including: the level of substances to which the user is exposed (which can be influenced by compensatory smoking); metabolism and absorption of the substances; and the pattern of use of the products (Hatsukami et al., 2004a).

III.2.1 Biomarkers of Exposure Biomarkers can be measured in urine, saliva, blood, exhaled breath, and other biological matrices. Important considerations for selecting the sample biological matrix have been described (American Conference of Governmental Industrial Hygienists, 2005). Table III-1 describes different biological sample matrices.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 50 Evaluation of Potential Reduced-Risk Tobacco Products , et meat et al i.e., , 2002) et al. , cotinine levels e.g. , 2005) 87) 9 et al. , 1 , muscle mass) and exogenous ( i.e. et al. -12 months) and less vulnerable to exposure 9 7). Biomarker levels are also influenced by last meal and time 99 3). Although spot or grab urine sampling may be more convenient , 1 99 to environmental tobacco smoke than hair (Al Delaimy Other considerations variations. Creatinine adjustment sometimes used to address variability, can also exhibit intra- and inter-individual variation, is affected by endogenous ( are higher in unstimulated than stimulated samples) (Schneider al. specificity (Degiampietro Less subject to intra-individual variability compared urine, saliva, or blood due to slow rate of hair growth (1 ± 0.3 cm/month). Inter- individual variability due to ethnicity and irregularity of hair growth across the scalp. Chemical and physical processing can lead to loss of some biomarkers (Al Delaimy, 2002) Less subject to variability than hair sampling due slower growth rate of toenails (1 cm/every Useful for measuring volatile compounds in breath. Changes concentration of biomarkers can occur during a breath (American Conference of Governmental Industrial Hygienists, 2005) consumption, physical activity, and urine flow) factors (Boeniger 1 than 24-hour sampling; more subject to urine volume variability and substance levels in urine (Barr since last cigarette was smoked (Stevens & Munoz, 2004) Duration of exposure measured Short-term For some biomarkers, blood samples show better sensitivity and long term (up to several months) long term exposure Very short- term Ease of sample collection difficult easy Biological sample matrix Urine Easy Short-term Differences in urine water content can contribute to biomarker level Saliva Easy Blood Moderately Short-term Hair Easy Relatively Collection method can influence biomarker levels ( Toenail Easy Relatively Exhaled air Relatively Table III-1. Considerations for Biological Sample Matrices for Studies of Biomarkers of Exposure Studies of Biomarkers Biological Sample Matrices for Considerations for III-1. Table

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LSRO evaluated and ranked biomarkers used to assess exposure to cigarette smoke based on the following desirable biomarker characteristics: • Tobacco-specificity/measurable alteration in tobacco users; • Low intra-individual variability; • Established pharmacokinetics; • Low analytical variability with good analytical sensitivity and chemical selectivity; and • Ease of sampling.

These rankings were used to categorize biomarkers of exposure: Category A: Biomarkers that have been sufficiently studied and provide reliable exposure measurements. Category B: Biomarkers that have sufficient data to support their use in exposure studies but also have limitations related to one or more desirable biomarker characteristics. Category C: Biomarkers that are not considered sufficiently reliable for routine use in exposure studies.

Tables III-2 and III-3 list the biomarkers of tobacco smoke exposure reviewed by LSRO. LSRO recommends biomarkers in Categories A and B (Table III- 2) for routine measurement of tobacco smoke exposure. LSRO does not recommend those in Category C (Table III-3) for routine use in exposure studies, although they may be used on an ad hoc basis. For example, Category C biomarkers provide information on exposure to particular (individual or classes of) smoke constituents; therefore, if smoke chemistry studies identify a particular constituent that is increased in PRRTP smoke, use of a Category C biomarker for that constituent may be appropriate.

These lists of biomarkers are not comprehensive; additional biomarkers should be measured if product design and composition, smoke chemistry, and/or toxicological studies warrant. Technological advances are to be expected in the detection and measurement of biomarkers of tobacco smoke exposure and new approaches and/or biomarkers should be considered for inclusion as they become available.

An exposure evaluation of a PRRTP should measure nicotine and at least five major metabolites, including cotinine. This is recommended because nicotine and cotinine are well established markers of tobacco smoke exposure, and the sum of nicotine, cotinine, and trans-3 -hydroxycotinine;′ and their glucuronide conjugates, nicotine-N-glucuronide, cotinine-N- glucuronide, and trans-3 -hydroxycotinine-′ O-glucuronide (measured in urine) accounts for 78% of total nicotine uptake (Benowitz, 1997).

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Table III-2 Biomarkers of Tobacco Smoke Exposure Recommended for Routine Use

Category A Biomarker Precursor Biological Comments/ matrix selected references

Nicotine and at least five Nicotine Urine Recommended for major nicotine inclusion in all exposure metabolites (including studies of PRRTP cotinine) (Balint et al., 2001; Byrd et al., 1992; Roethig et al., 2005) Carbon monoxide (CO); CO Exhaled (Cunnington & Hormbrey, Carboxyhemoglobin breath; 2002; Hughes & Keely, (COHb) blood 2004; Smith et al., 1998; Wald et al., 1981b) Urine mutagenicity Mutagens, Urine (Bowman et al., 2002; carcinogens Roethig et al., 2005) 1-Hydroxypyrene Pyrene Urine Surrogate for polycyclic aromatic hydrocarbons (PAH) (Hatsukami et al., 2004c; Murphy et al., 2004) 3-Hydroxypropyl- Acrolein Urine (Mascher et al., 2001) mercapturic acid Trans, trans-muconic Benzene Urine (Scherer et al., 1998) acid (tt-MA) S-phenyl-mercapturic Benzene Urine (Boogaard & van Sittert, acid (S-PMA) 1995) Monohydroxy-butenyl- 1,3- Urine (Urban et al., 2003; van mercapturic acids Butadiene Sittert et al., 2000) (MHBMA or MII) 4-(methylnitrosoamino)- Tobacco Urine (Breland et al., 2003; 1-(3-pyridyl)-1-butanol specific Hughes et al., 2004) (NNAL) and glucuronide nitrosamines (TSNAs) 4-Aminobiphenyl 4-amino- Blood (Bartsch et al., 1990) hemoglobin adducts biphenyl N-(2-cyanoethyl)valine Acrylonitrile Blood (Fennell et al., 2000; hemoglobin adducts Perez et al., 1999; Schettgen et al., 2002)

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Table III-2. Biomarkers of Tobacco Smoke Exposure Recommended for Routine Use (continued)

Category B Biomarker Precursor Biological Comments/ matrix selected references Acetonitrile Acetonitrile Exhaled (Houeto et al., 1997; Lirk breath et al., 2004) Anabasine, anatabine Minor Urine (Jacob III et al., 1999; tobacco 2002) alkaloids Dihydroxybutenyl- 1,3- Urine (Urban et al.,2003; van mercapturic acids butadiene Sittert et al., 2000) (DHBMA or MI) 3-Hydroxybenz[a] Benz[a] Urine (Gündel & Angerer, 2000; anthracene anthracene Simon et al., 2000) 3-Hydroxybenzo[a] Benzo[a] Urine (Gündel & Angerer, 2000; pyrene pyrene Simon et al., 2000)

Category A: Biomarkers that have been sufficiently studied and provide reliable exposure measurements. Category B: Biomarkers that have sufficient data to support their use in exposure studies but also have limitations related to one or more desirable biomarker characteristics. PRRTP: potential reduced-risk tobacco product

Nicotine (and its metabolites) should be one component of a battery of biomarkers chosen to assess exposure to particulate and vapor phase smoke constituents and relevant toxic chemicals. Table III-4 provides an example of a battery of biomarkers for exposure studies of tobacco smoke from PRRTPs and conventional cigarettes. This battery should not be interpreted as prescriptive or appropriate to all situations. Product characteristics, results of chemical analysis results, and other relevant information should be used to guide the selection of biomarkers most relevant to the PRRTP being studied. The rationale for selection of biomarkers to be included in PRRTP exposure studies should be provided.

III.2.2 Smoking Topography Smoking topography is a method to assess the delivery of external toxicant to the lung (Institute of Medicine, 2001). Parameters measured by smoking topography methods include puff volume, puff duration, inter-puff interval, maximum puff velocity, puffs per cigarette, inhalation depth, inhalation volume, length of time to smoke a cigarette, and total inhalation time (Lee et al., 2003). Wide variability in inter- and intra-individual cigarette puffing behavior has been observed (Byrd et al., 1998; Djordjevic et al., 2000; Jarvis et al., 2001; U.S. Department of Health and Human Services, 1988).

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Table III-3. Biomarkers of Tobacco Smoke Exposure Not Recommended for Routine Use

Category C Biomarker Precursor References N-Acetyl-S-(2- Acrylamide (Boettcher & Angerer, carbamoylethyl)-L- 2005; Boettcher et al., cysteine (AAMA) and N- 2005) (R,S)-acetyl-S-(2- carbamoyl-2- hydroxyethyl)-L-cysteine (GAMA) 1-, 2-, 3-, and 4- Aromatic amines (Grimmer et al., 2000; Aminonaphththalene Riffelmann et al., 1995) Benzene Benzene (Jordan et al., 1995) Cadmium Cadmium (Jarup et al., 1998; Satarug et al., 2004) 2, 5-Dimethylfuran 2, 5-Dimethylfuran (Ashley et al., 1996 ; Perbellini et al., 2003) 1- and 2-Naphthols Naphthols (Nan et al., 2001; Yang et al., 1999) Thiocyanate Hydrogen cyanide (Degiampietro et al., 1987; Torano & van Kan, 2003) 1-, 2-, 3- and 4- Phenanthrenes (Heudorf & Angerer, 2001; Hydroxyphenanthrenes Jacob et al., 1999) Thioethers Electrophilic compounds (Feng et al., 2006) 3-Methyladenine in urine Methylating substances (Prevost et al., 1990) 3-Ethyladenine in urine Ethylating substances (Kopplin et al., 1995; Prevost & Shuker, 1996) 5-(Hydroxymethyl)uracil Reflects DNA damage (Pourcelot et al., 1999) by oxygen free radicals Nitrosated proteins Nitric oxide (Hoffmann & Brunnemann, 1983; Ladd et al., 1984) 1, 3-Butadiene adducts 1, 3- butadiene (Fustinoni et al., 2002) Benzo[a]pyrene albumin Benzo[a]pyrene (Autrup et al., 1995; adducts Crawford et al., 1994; Sherson et al., 1990; Tas et al., 1994) Benzo[a]pyrene Benzo[a]pyrene (Grimmer et al., 1987; Hemoglobin (Hb) adducts Hoffmann & Hoffmann, 1997) Bulky DNA adducts Large, primarily apolar (Phillips, 2002) compounds such as polycyclic aromatic hydrocarbons (PAHs), aromatic amines, and others

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Table III-3. Biomarkers of Tobacco Smoke Exposure Not Recommended for Routine Use (continued) Category C Biomarker Precursor References Etheno adducts Vinyl chloride, lipid (Albertini et al., 2003) peroxidation-derived products

F2-Isoprostanes Arachidonic acid (Chehne et al., 2002; Pilz peroxidation et al., 2000; Reilly et al., 1996) Aromatic amine DNA Aromatic amines (Flamini et al., 1998; Hsu adducts et al., 1997) 4-Hydroxy-1-(3-Pyridyl-1- Tobacco-specific (Foiles et al., 1991) butanone (HPB) DNA nitrosamines (TSNAs) adducts 4-Hydroxyl-1-(3-pyridyl)- TSNAs (Falter et al., 1994; Hecht 1-butanone (HPB)-Hb et al., 1991) adducts

8-Hydroxy-2'- Marker of hydroxyl (Daube et al., 1997) deoxyguanosine radical damage to DNA N(-2-hydroxyethyl)valine Ethylene or ethylene (Fennell et al., 2000; Hb adducts oxide Schettgen et al., 2002) 7-Methylguanine adducts Methylating agents such (Mustonen & Hemminki, as 4- 1992; Mustonen et al., (Methylnitrosamino)-1- 1993) (3-pyridyl)-1-butanone (NNK) and Nitrosodimethylamine (NDMA) N-(2-Carbamoylethyl) Acrylamide (Bergmark, 1997; Hagmar valine Hb adducts et al., 2005) PAH-DNA adducts PAHs (Kriek et al., 1998; Mooney et al., 1995 ; Tang et al., 1995) N-Ethylvaline Hb adducts Not known, possibly (Carmella et al., 2002) nitrosation of ethylamine, acetonitrile N-Methylvaline Hb NDMA, NNK methyl (Bader et al., 1995; adducts halides and other Carmella et al., 2002) substances

Category C: Biomarkers that are not considered sufficiently reliable for routine use in exposure studies.

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Table III-4. Sample Battery of Biomarkers of Tobacco Smoke Exposurea

Biomarker Phase of Class of compounds smoke measured Nicotine + 5 major metabolites Particulate Nicotine

4-Aminobiphenyl hemoglobin Particulate Aromatic amines adducts CO in exhaled air or COHb Vapor CO 1-Hydroxypyrene Particulate PAHs NNAL and NNAL-glucuronide Particulate TSNAs S-Phenylmercapturic acid or Vapor Volatile aromatic trans, trans-muconic acid hydrocarbons Urine mutagenicity Particulate Mutagens

aThis is a hypothetical battery. It is not intended to be prescriptive. CO: carbon monoxide; COHb: carboxyhemoglobin; PAHs: polycyclic aromatic hydrocarbons; TSNAs: tobacco-specific nitrosamines

III.2.3 Other Measures of Exposure Assessment of particle deposition and retention, filter analysis methods, microarray (e.g., messenger RNA) expression in peripheral leukocytes, analysis of induced sputum, and analysis of exhaled breath can provide useful information to supplement biomarker assays of tobacco smoke exposure.

III.2.4 Interpretation of Exposure Study Results To conclude that exposure to various constituents are reduced, differences between biomarker levels following PRRTP and/or control cigarette use should be statistically significant. Biomarker measurements in PRRTP users that more closely resemble those of nonsmokers or ex-smokers (versus smokers), increase confidence in the conclusion that a PRRTP reduces exposure.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Clinical Studies 57 III.3 CLINICAL STUDIES OF EFFECT Disease pathogenesis is a complex, multi-step process. Molecular, cellular, tissue, and organ events associated with the development of lung cancer (LC), chronic obstructive pulmonary disease (COPD), and cardiovascular disease (CVD) can be used to assess differences in adverse health effects associated with PRRTP or conventional cigarette use.

III.3.1 Biomarkers of Effect Desirable characteristics of biomarkers used to assess biological effects include: • Smoking is known to directly or indirectly affect the biomarker; • The biomarker is known to be associated with pathobiology and clinical events of the disease of interest; • The biomarker is readily reversible; • The timeframe needed to see a change in the biomarker is appropriate for premarket testing (i.e., months, weeks, days); and • Use of the biomarker is practical, in terms of intra-individual variability; availability of measurement methodology; analytical reproducibility, sensitivity, specificity, and/or standardization; acceptability to subjects; and cost.

Biomarkers used to study effect must be relevant to the biological pathways of the disease being investigated. LSRO considers these biological processes relevant (but not necessarily causal) to the development of LC, COPD, and CVD: • LC: Cytopathological changes, genetic damage, epigenetic alterations, inflammation, oxidative stress, protein changes; • COPD: Airway obstruction and/or clinical severity, inflammation, protease-antiprotease imbalance, oxidative stress, parenchymal destruction, epithelial injury, mucus production; and • CVD: Lipid metabolism, inflammation, thrombosis and coagulation, oxidative stress, endothelial function, atherosclerosis, myocardial function, and electrical cardiac activity.

Biomarkers that could be used to study these biological processes were classified as primary, secondary, or tertiary using the following criteria: • Primary biomarkers have been linked to clinical outcomes with strong evidence. • Secondary biomarkers have been linked to clinical outcomes with moderate evidence. • Tertiary biomarkers have been linked to clinical outcomes with preliminary evidence.

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Table III-5 lists biomarkers that could be used to study the biological effects described above. Each biomarker is listed according to its relevant disease and biological process and is classified as primary, secondary, or tertiary. This list was developed based on the collective scientific judgment of LSRO and is not intended to be prescriptive or limiting. The list is not comprehensive and will change with time. As scientific and medical knowledge progress and analytical capabilities expand, additional measures may become available and data on existing biomarkers may become more established.

III.3.1.1 Lung cancer biomarkers All common histological types of lung cancer are associated with cigarette smoking: squamous cell carcinoma, adenocarcinoma, small cell carcinoma, and large cell carcinoma (Rubin, et al., 2005). Several pathological stages have been defined for squamous cell carcinoma: hyperplasia, metaplasia, dysplasia, and carcinoma in situ (Rubin et al., 2005). The cellular changes associated with squamous dysplasia in the large airways have a strong relationship to smoking, pathobiology, and disease (Bota et al., 2001; Wistuba et al., 1999), although squamous cell dysplasia is often irreversible. Hyperplasia and metaplasia are reversible and have been shown to regress after smoking cessation (Hirsch, et al., 2001); however, their relationship to the development of squamous cell carcinoma is not as strong. Adenocarcinoma, small cell carcinoma, and large cell carcinoma have less well defined preneoplastic changes. Because of shortcomings of cytopathological lesions as biomarkers of effect for squamous cell carcinoma and the absence of definitive preneoplastic cytopathology for the remaining types of lung cancer, additional test methods must be used to evaluate LC risk.

Panels of biomarkers that detect early steps in the carcinogenic process, such as alterations in DNA methylation patterns, changes in proteomic profiles, or gene mutations that result in the loss of, or functional changes in, cell cycle, signal transduction, DNA repair, and tumor-suppressor proteins, can provide information on PRRTP effects in smokers. Recently, promoter hypermethylation of multiple genes in sputum was shown to precede LC in a high-risk cohort of individuals with a smoking history of ≥ 30 pack-years.11 Methylation of three or more genes in sputum collected within 18 months of diagnosis was associated with a 6.5-fold increase in the risk of LC (Belinsky et al., 2006). With further development, gene array and proteomic technologies may become an ideal platform for rapid, automated screening of a number of biomarkers representing multiple biological processes that contribute to LC.

11 “Pack-year” is a unit of measure for smoking exposure. One pack-year represents the consumption of 20 cigarettes per day (one pack) for one year by one person.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Clinical Studies 59 have been linked to clinical been linked have c Gene array technologies Inflammatory markers in respiratory tract fluids or tissues Proteomic technologies Secondary biomarkers b Tertiary b Secondary squamous cell carcinoma Cytology and pathology (sputum, forceps and brush biopsy) for other histological tumor types Spiral CT Chromosomal aberration Micronuclei Aneuploidy Loss of heterozygosity Acquired genetic effects to specific targets DNA adducts Urine mutagenicity levels Inactivated or activated proteins/enzymes/receptors Protein adducts : lung cancer : have been linked to clinical outcomes with preliminary been linked evidence. have LC a Tertiary biomarkers Tertiary c Primary Squamous cell dysplasia Hyperplasia and metaplasia for : deoxyribonucleic acid; acid; deoxyribonucleic : DNA have been linked to clinical outcomes with strong evidence. to clinical outcomes with strong evidence. been linked have

Disease/Biological process LC Cytopathological changes Genetic damage Epigenetic alterations Inflammation Oxidative stress Protein changes DNA methylation Oxidative DNA products Abnormal or elevated proteins Isoprostanes Table III-5. Biomarkers for Measuring Biological Effect for Biomarkers III-5. Table : computed tomography; computed tomography; : Primary biomarkers CT outcomes with moderate evidence. evidence. outcomes with moderate a

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 60 Evaluation of Potential Reduced-Risk Tobacco Products : exhaled breath exhaled : : positron emission : EBC PET -isoprostane have been linked to clinical been linked have 2 c and reactive nitrogen 2 O 2 Clara cell (CC16) and surfactant protein plasma levels Histone deacetylase activity In alveolar macrophages Exhaled NO NO-derived products and inflammatory mediators in exhaled-breath condensate PET scans Urinary desmosine H intermediates in EBC Urinary F in arterial blood; in arterial blood; 2 ) or CO 2 Secondary biomarkers b

continued diffusing capacity for carbon monoxide; carbon monoxide; diffusing capacity for

: Tertiary b CO DL : partial pressure of O : 2 Tc-DTPA clearance -isoprostane and aldehydes in 2 m

Secondary bronchoscopy Neutrophils, macrophages, T- lymphocytes, eosinophils, chemokines, and cytokines in sputum and bronchoalveolar lavage fluid sputum and bronchoalveolar lavage fluid 99 EBC

CO pa / 2 O have been linked to clinical outcomes with preliminary been linked evidence. have pa ) 2 a : nitric oxide; nitric oxide; : / paCO 2 /FVC NO

1 1 CO Tertiary biomarkers Tertiary c (paO Arterial blood gases Respiratory symptoms FEV DL Proteases and protease activity in FEF 25–75% FEV Quantitative CT imaging technetium-labeled diethylenetriamine penta-acetic acid : chronic obstructive pulmonary disease; pulmonary chronic obstructive disease; : 99m : have been linked to clinical outcomes with strong evidence. to clinical outcomes with strong evidence. been linked have COPD : hydrogen peroxide; peroxide; hydrogen : 2 Tc-DTPA O 2 H 99m Disease/Effect Primary COPD Airway obstruction and/or clinical severity Inflammation Protease-antiprotease imbalance Oxidative stress Parenchymal destruction Epithelial injury Airway appearance by F Table III-5. Biomarkers for Measuring Biological Effect ( Measuring Biological Effect for Biomarkers III-5. Table : carbon dioxide; carbon dioxide; : 2 Primary biomarkers CO outcomes with moderate evidence. evidence. outcomes with moderate a condensate; condensate; tomography; tomography;

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) : low-density lipoprotein low-density : Secondary biomarkers LDL b

continued Tertiary b -isoprostane 2 Triglycerides LDL particle size and density Serum amyloid A Cytokines Cell adhesion molecules Matrix metalloproteases White blood count Platelet function Plasmin-antiplasmin complex Urinary F Brachial artery responsivity Asymmetric dimethylarginine Pulse-waveform analysis Ankle-brachial blood pressure index Secondary : high-density lipoprotein; high-density lipoprotein; : have been linked to clinical outcomes with preliminary been linked evidence. have HDL a Tertiary biomarkers Tertiary HDL cholesterol Fibrinogen D-dimer thickness Coronary calcification EKG Holter monitoring c : electrocardiogram; electrocardiogram; : EKG have been linked to clinical outcomes with strong evidence. to clinical outcomes with strong evidence. been linked have Table III-5. Biomarkers for Measuring Biological Effect ( Measuring Biological Effect for Biomarkers III-5. Table Disease/Effect Primary Inflammation C-reactive protein CVD Lipid metabolism Inflammation C-reactive LDL cholesterol Thrombosis and coagulation Oxidative stress intima-media Endothelial function Atherosclerosis Carotid Myocardial function Electrical cardiac activity Heart rate variability Echocardiogram Oxidized LDL von Willebrand factor : cardiovascular disease; disease; cardiovascular : Primary biomarkers CVD outcomes with moderate evidence. evidence. outcomes with moderate a

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III.3.1.2 Pulmonary disease biomarkers

Airflow measurements such as FEV1 and FEF25–75% are primary biomarkers and have the strongest relationship to cigarette smoke-related respiratory tract pathobiology (e.g., COPD). However, they may not be useful in PRRTP testing because they measure cumulative damage caused by years of cigarette smoking and identify individuals who already have existing airflow reductions, a defining feature of COPD (Camilli et al., 1987; Dockery et al.,

1988). Similarly, measurements of DLCO and quantitative CT imaging are used to assess the extent of parenchymal damage caused by emphysema and may not be useful for premarket PRRTP assessments because they identify disease caused by cumulative damage over time.

A number of secondary biomarkers for airway inflammation, an earlier biological effect related to development of COPD, are available including airway appearance by bronchoscopy and the measurement of neutrophils, macrophages, T- lymphocytes, eosinophils, chemokines, and cytokines in bronchoalveolar lavage fluid. However, the use of such assessment techniques are invasive and expensive (Rennard et al., 2002), which limits the practicality of these methods.

Other, less invasive methods of obtaining samples to assess cellular, protein, and volatile biomarkers of inflammation, such as sputum induction (Wilson et al., 2006) or the collection of exhaled breath condensate (Montuschi & Barnes, 2002), are available and have sufficient evidence for use as secondary biomarkers. Biomarkers of other pathobiological processes associated with COPD may also be useful in PRRTP assessments. For example, 99mTechnetium-labeled-diethylenetriamine penta-acetic acid clearance, a biomarker that reflects the permeability of the respiratory epithelium, rapidly changes in response to cigarette smoking (Huchon et al., 1984; Jones et al., 1980; Kennedy et al., 1984; Mason et al., 1983; Minty et al., 1981; Stewart et al., 2006). A number of additional secondary biomarkers for COPD are available for use in PRRTP assessments (see Table III-5).

III.3.1.3 Cardiovascular disease biomarkers As was noted for several biomarkers for LC and COPD, the usefulness of cardiovascular biomarkers that detect advanced disease and reflect cumulative, long-term effects, such as carotid intima-media thickness (van den Berkmortel et al., 2004) and coronary calcification (Simon et al., 1995),for PRRTP assessments are of limited utility.

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A number of other primary cardiovascular biomarkers, however, can be used in PRRTP assessments. Much of the available evidence on these biomarkers has been derived from prospective studies. The Framingham Risk Score, an assessment based on age, serum cholesterol levels, blood pressure, and comorbidities such as cigarette smoking and diabetes, is used in clinical practice to identify individuals who may be at high risk for coronary heart disease (Grundy et al., 1999).

Measurement of C-reactive protein levels may provide additional risk information for individuals with intermediate Framingham Risk Scores (Pearson et al., 2003). Plasma fibrinogen is also an independent CVD risk factor (Danesh et al., 1998; Ernst & Resch, 1993; Kannel et al., 1987; Wilhelmsen et al., 1984) and cross-sectional studies have shown that fibrinogen levels are elevated in smokers (Ernst & Resch, 1993; Folsom et al., 1991, 1992; Miller et al., 1998).

Measuring cardiovascular biomarkers of inflammation and oxidative stress, including cytokines (Ridker et al., 2000a,b; Skoog et al., 2002), cell adhesion molecules (Haim et al., 2002; Hwang et al., 1997; Ridker et al., 1998, 2001; Rohde et al., 1998), and oxidized LDL (Fredrikson et al., 2003; Holvoet et al., 2001; 2003), adds to the information provided by traditional risk factors.

Some newer measures (e.g., F2-isoprostane) show a clear association with cigarette smoking, but require additional study to clarify their relationship to CVD pathogenesis (Morrow et al., 1995; Morrow, 2005; Oguogho et al., 2000).

III.3.2 Selection of Biomarkers of Effect LSRO concluded that a battery of biomarkers of effect for LC, COPD, and CVD should be used to assess the relative toxicities and risks of PRRTP compared to conventional cigarettes. Table III-6 provides an example of a battery of tests to measure biomarkers of effect for the three disease endpoints.

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Table III-6. An Example of a Battery of Biomarkers of Effect for LC, COPD, and CVDa

LC A study investigating potential mutagenic and carcinogenic lung (or pulmonary) effects of a PRRTP might assess: • Genetic damage (panels of markers detecting chromosomal aberrations, gene mutations in cell cycle, signal transduction, DNA repair, and tumor-suppressor proteins; urine mutagenicity; and/or adduct formation) • Cytopathological changes (cytology and pathology of cells or tissue obtained from sputum samples and/or biopsy; spiral CT) • Epigenetic alterations (DNA methylation)

COPD A study investigating the potential effects of a PRRTP on the respiratory function might measure: • Airway obstruction and/or clinical severity (FEV1, FEF25-75%) • Epithelial injury (99mTc-DTPA clearance, Clara cell protein) • Inflammation (inflammatory cells in sputum/BALF, exhaled NO) • Oxidative stress (exhaled F2-isoprostane, H2O2, and/or malondialdehyde)

CVD For a more complete picture of physiological changes, a study investigating the potential cardiovascular effects of a PRRTP might measure: • Lipid metabolism (HDL cholesterol, LDL cholesterol, triglycerides); • Inflammation (C-reactive protein, fibrinogen, WBC, cytokines); • Thrombosis and coagulation (D-dimer, platelet function, plasmin-antiplasmin complex formation); and • Endothelial function (vWF, brachial artery responsivity)

aThis is a hypothetical battery. It is not intended to be prescriptive. BALF: bronchoalveolar lavage fluid; COPD: chronic obstructive pulmonary disease; CVD: cardiovascular disease; CT: computed tomography; DNA: deoxyribose nucleic acid; EBC:

exhaled breath condensate HDL: high-density lipoprotein; H2O2: hydrogen peroxide; LDL: low-density lipoprotein; NO: nitric oxide; PRRTP: potential reduced-risk tobacco product; RBC: red blood cell; 99mTc-DTPA: 99mtechnetium-labeled diethylenetriamine penta-acetic acid; vWF: von Willebrand factor; WBC: white blood cell

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Clinical Studies 65 III.4 CONCLUSIONS AND RECOMMENDATIONS LSRO concluded that biomarkers of exposure can be relied upon in clinical studies to determine whether exposure due to PRRTPs use is less than exposure due to conventional cigarettes. • LSRO recommends using a battery of exposure biomarkers to evaluate a PRRTP to ensure that exposure comparisons adequately address exposure to smoke constituents. • LSRO recommends that all evaluations include nicotine, cotinine, trans-32-hydroxycotinine, and their glucuronide conjugates (nicotine- N-glucuronide, cotinine-N-glucuronide, and trans-32- hydroxycotinine-O-glucuronide). • Batteries of exposure biomarkers should include biomarkers present in particulate and vapor phases as well as specific constituents of interest.

LSRO concluded that well-conducted, comprehensive clinical studies that include multiple biomarkers of effect for LC, COPD, and CVD can provide evidence on the relative toxicity and risk of PRRTP compared to conventional cigarettes. Biomarkers of molecular, cellular, tissue, and organ events associated with the development of LC, COPD, and CVD from cigarette smoking can provide data to assess differences in risks of adverse health effects associated with PRRTPs or conventional cigarette use.

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IV.1 INTRODUCTION IV.1.1 Context and Purpose of a Risk Assessment IV.1.2 Treatment of Scientific Uncertainty IV.1.3 Weight of Evidence IV.1.4 PRRTP Risk Assessments

IV.2 EXPOSURE ASSESSMENT IV.2.1 Human Biomarker Studies IV.2.2 Smoking Topography IV.2.3 Chemistry Studies IV.2.4 Weight of Evidence: Exposure

IV.3 BIOLOGICAL EFFECTS ASSESSMENT IV.3.1 Clinical Studies of Biomarkers of Effect IV.3.2 Preclinical Studies IV.3.3 Weight of Evidence: Biological Effects Assessment

IV.4 RISK CHARACTERIZATION

IV.5 CONCLUSIONS AND RECOMMENDATIONS

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Comparative Risk Assessment 67 COMPARATIVEIV RISK ASSESSMENT IV.1 INTRODUCTION A human health risk assessment is a systematic review and evaluation of data relating to the risks posed by occupational or environmental chemicals, consumer products, food components and drugs, and other potentially hazardous substances (National Research Council, 1983). The risk assessment process described here is based on methods and approaches developed and refined over 30 years; these methods have been summarized in guidance documents developed by federal regulatory agencies and others (National Research Council, 1983, 1994; U.S. Environmental Protection Agency, 2005).

IV.1.1 Context and Purpose of a Risk Assessment A risk assessment is always conducted within a particular context (National Research Council, 1983, 1994). The context and purpose of a risk assessment affects its content and analytical approach. For example, regulatory agencies often conduct “screening level” assessments that use worst-case scenarios to prioritize the risks that need to be assessed. Higher priority risks are then assessed more thoroughly and rigorously to develop a realistic risk profile for use in the regulatory process (National Research Council, 1983, 1994; U.S. Environmental Protection Agency, 2005).

Legal requirements for a particular product or environmental medium determine how federal regulatory agencies conduct a risk assessment. For example, the statute covering the removal of a pesticide from the market requires that a lower-risk alternative be available before its registration can be cancelled (U.S. Environmental Protection Agency, 1996, 2006a). In contrast, assessing toxic air contaminants under the Clean Air Act (U.S. Environmental Protection Agency, 1970, 2006b) requires a demonstrated margin of safety for the proposed regulatory limit and considerations such as cost or feasibility may not be considered.

IV.1.2 Treatment of Scientific Uncertainty Doull et al. (1996) observed, “It has long been recognized that there are relatively few absolutes in biology, and that any interpretation of observed

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phenomena must be tempered with sound scientific judgment.” Gaps (or uncertainties) in scientific knowledge are encountered in all human health risk assessments (National Research Council, 1983, 1994; U.S. Environmental Protection Agency, 2005). To complete an assessment, gaps are addressed by informed assumptions about what is most likely to be correct (“scientific inference/judgment”) or most likely to protect human health (“risk assessment policy”) (National Research Council, 1983, 1994; U.S. Environmental Protection Agency, 2005). This reliance on assumptions is necessary and appropriate “as a kind of intellectual glue cementing together the evidence and the [evaluation] methods” (Weed, 2005). Examples of scientific uncertainties and assumptions in PRRTP assessment are listed in Table IV-1.

Table IV-1. An examples of Scientific Uncertainties and Assumptions Scientific Uncertainties Assumptions

Relationship between exposure to Demonstrated reduction in one or smoke constituents and development more toxicants indicate potential of disease reductions in disease risk

Animal models to human disease Evidence of reduced toxicity in outcomes animals indicates the potential for reduced risk of disease in humans

Degree of exposure reduction As exposure is reduced, risk is also needed to reduce disease risk likely to be reduced

Role of current identifiable Changes in biomarkers of effect biomarkers of effect in disease associated with decreased disease causation/development risk indicate risk reduction

Risk assessments are significantly more clear and credible when facts (i.e., actual data) are clearly distinguished from assumptions based on judgment (e.g., expert interpretation of data) and risk assessment policy (e.g., inference options applied to all similar risk assessments) (U.S. Environmental Protection Agency, 2005). This clarity contributes to the transparency of the risk assessment.

IV.1.3 Weight of Evidence Weight of evidence is a process that assigns different levels of importance (weights) to evidence based on a number of factors. Weight of evidence also refers to conclusions based on the totality of the evidence from all study types.

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Because the critical decision for a PRRTP is whether a health-related claim can be made (Institute of Medicine, 2001), Life Science Research Office (LSRO) recommends using a weight of evidence approach for PRRTPs modeled after an evidence-based ranking system used by the US Food and Drug Administration (FDA) for potential health claims for foods (Table IV-2) (U.S. Food and Drug Administration, 2003).

IV.1.4 PRRTP Risk Assessments PRRTP risk assessments are comparative. The issues are: whether exposures to toxic constituents in PRRTP emissions are lower than exposures to toxic constituents present in conventional cigarettes; and whether biological effects measured in PRRTP users are indicative of reduced risk compared to effects measured in users of conventional cigarettes.

Based on the totality of evidence from exposure and biological effects assessments, an overall conclusion (i.e., risk assessment) is reached. The risk characterization should answer the following questions: • What is the overall weight of evidence that a PRRTP reduces risks of lung cancer (LC), chronic obstructive pulmonary disease (COPD), and/or cardiovascular disease (CVD) in continuing smokers compared to the risks currently posed by conventional cigarettes? • What is the magnitude of the reduction? • What is the degree of confidence in the answers to the preceding questions?

LSRO designed the testing process described in the preceding chapters to provide the data needed to answer these questions. The sequence of testing— chemistry, cytotoxicity and genotoxicity assays, and clinical studies of exposure and effect—reflects the increasing “weight” given to each type of testing (e.g., results from clinical studies are accorded greater weight than results from chemistry studies).

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Table IV-2. Steps in the FDA Process Applied to PRRTPs Steps in the FDA Process Application to PRRTPs Define the product/disease risk Evaluate effects of PRRTPs on risks of relationship[s] being assessed LC, COPD, and CVD associated with smoking conventional cigarettes Collect all relevant (favorable and Collect positive and negative clinical unfavorable) studies studies for exposure and risk reduction as well as studies of smoke chemistry, cytotoxicity and genotoxicity assays, and animal toxicity studies Classify and rank (based on the Rank human studies in descending principle of minimizing bias) each order: randomized controlled studies; study based on type of experimental prospective observational cohort design and quality studies; and nonrandomized clinical studies. Rank supportive studies in descending order: animal models; animal toxicity studies; cytotoxicity and genotoxicity assays; and chemistry studies. Rank the quality of human and supporting studies on such factors as: inclusion and exclusion bias; generality; and data collection and analysis Quantity: number and size of Determine whether the number or size of studies studies is sufficient to the target population (continuing smokers)

Consistency: studies of similar and Studies have consistent results, and any different designs report similar inconsistencies can be satisfactorily findings explained

Relevance to risk reduction Magnitude of the effect is physiologically meaningful and achievable in target population Rank the evidence based on the High level of confidence reflects very low level of confidence among qualified level of probability such that significant scientists that the finding of risk new data would not overturn the reduction is valid conclusion (“significant scientific agreement”); moderate/good level of confidence reflects conclusion such that the relationship is promising but not definitive; low level of confidence indicates high degree of uncertainty regarding risk reduction potential

COPD: chronic obstructive pulmonary disease; CVD: cardiovascular disease; LC: lung cancer; PRRTP: potential reduced-risk tobacco product

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Comparative Risk Assessment 71 IV.2 EXPOSURE ASSESSMENT The exposure assessment step is intended to compare exposure to smoke between conventional cigarettes and PRRTPs; this will determine the weight of the evidence for reduced exposure and the magnitude of the reduction. Studies used to assess exposure reduction are (in descending order of assigned weight): human biomarker of exposure studies, human smoking topography studies, and product smoke chemistry studies.

IV.2.1 Human Biomarker Studies Biomarkers of exposure integrate factors that determine internal exposure to tobacco product and smoke constituents. A number of biomarkers of exposure have been sufficiently characterized (see Chapter III) to provide when used in properly designed and executed clinical studies, reliable exposure estimates. Confidence in conclusions based on biomarker studies increases when multiple biomarkers—such as those biomarkers for both vapor and particulate phase exposures—are included. Assessment of biomarkers for specific toxicants that smoke chemistry studies identify as “of interest” (i.e., significant increases or decreases are seen) is also important. Finally, comparable results reported for several independent studies strongly supports a conclusion that exposure is reduced.

IV.2.2 Smoking Topography Incorporating smoking topography measures into biomarker studies can elucidate the relationship between smoking behavior and exposure, which in turn contributes to the overall weight of evidence for exposure reduction.

IV.2.3 Chemistry Studies Studies of the chemical composition of PRRTP smoke alone do not provide data to estimate human exposure; however, consistent chemistry and human biomarker of exposure study results increase confidence in conclusions about exposure reduction. Inconsistent results reduce that confidence, unless a scientifically valid rationale is provided.

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IV.2.4 Weight of Evidence: Exposure Clinical data using biomarkers of exposure are most relevant to assess reduced exposure. Optimally, clinical biomarker data would: • Be consistent across several reliable, independent, well-designed, and well-conducted studies; • Have been analyzed using appropriate statistical methods from studies of an appropriate battery of biomarkers for particulate and vapor phases of smoke; • Represent findings on specific toxic constituents of interest; and • Be consistent with findings from preclinical studies.

IV.3 BIOLOGICAL EFFECTS ASSESSMENT The purpose of this step is to develop conclusions about (1) whether the PRRTP is likely to pose different LC, COPD, and/or CVD risks than conventional cigarettes; and (2) the magnitude of the differences seen. Studies used to assess biological effects are (in descending order of assigned weight): clinical studies of biomarkers of effect, animal studies, and cytotoxicity and genotoxicity assays.

IV.3.1 Clinical Studies of Biomarkers of Effect Biomarkers of effect must be relevant to biological pathways of the studied disease to be meaningful. Evidence of risk reduction should be assessed separately for each disease. LSRO concluded that a number of biomarkers of biological effect considered relevant to the risk of LC, COPD, or CVD are available.

Statistically and biologically significant changes indicative of decreased risk12 of effect in PRRTP users compared to those in conventional cigarette smokers support the likelihood that risks of LC, COPD and/or CVD will be lower for PRRTP users.

Confidence in conclusions of reduced risk of disease is increased by consistent findings across studies using multiple biomarkers for multiple disease pathways. Inconsistent findings, including evidence of increased risk, weaken the confidence in conclusions of reduced risk in the absence of scientifically sound rationale for the inconsistency.

12 Biomarkers of effect can be either directly or inversely associated with risk (e.g., an increase in HDL-cholesterol and a decrease in LDL-cholesterol are both associated with a decreased risk of CVD).

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IV.3.2 Preclinical Studies Data from cytotoxicity and genotoxicity assays provide the first indication of whether a PRRTP may reduce the incidence and/or severity of adverse biological effects. Consistent findings from several assays of each endpoint strengthen conclusions regarding reductions in toxicity associated with the PRRTP.

Standard animal toxicology studies (i.e., acute, subchronic, and chronic) also provide information on the relative toxicity of a PRRTP; however, because the studies are conducted in species more closely related to humans (e.g., rats and mice compared to bacteria or tissue-culture cells), the results have greater relevance to PRRTP effects on smokers. Confidence in findings from animal studies is increased when consistent effects for similar study designs are observed in at least two animal species.

Validated animal models of disease provide the most relevant preclinical data on the potential of a PRRTP to reduce the risks associated with smoking.

IV.3.3 Weight of Evidence: Biological Effects Assessment Clinical data using biomarkers of effect are most relevant to assess the likelihood that risk will be reduced in smokers who use a PRRTP. Preclinical studies of genotoxicity, cytotoxicity, animal toxicity, and animal models of disease can provide ancillary data on potential reductions in human risk and contribute to the overall weight of evidence.

IV.4 RISK CHARACTERIZATION In the risk characterization, individual weight of evidence conclusions are developed for the exposure and the biological effects assessments. Confidence in conclusions that exposure and risk are reduced for LC, COPD, and/or CVD increases with: (1) the number of studies demonstrating that relationship; (2) the number of different approaches and endpoints measured for each study type (e.g., different study designs and test settings for preclinical and clinical studies); (3) the validity of each measure for assessing tobacco or smoke constituent exposure and biological effects; (4) statistical significance of the differences between a PRRTP and control cigarettes; (5) the degree of differences in exposure/effect; (6) relevance of the studies to humans; and (7) the number of reliable studies showing consistent results. Studies of biological effects are given greater weight when a dose-response relationship is demonstrated.

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Scientifically sound rationales that explain specific inconsistencies increase confidence in conclusions, and the importance accorded inconsistent results should be based on the weight given to the study types of studies producing these results. So, results from studies that are more relevant to actual product users outweigh those from less relevant studies (e.g., an inhalation exposure study is more relevant than a dermal exposure study). If inconsistencies cannot be adequately explained, additional research may be required to resolve disparate results.

A set of overall conclusions is developed based on the exposure and effects assessment results. The overall weight of evidence determination is based on qualified scientists’ degree of confidence in the scientific validity of results and conclusions. The degree of confidence also depends on how, and how well, scientific uncertainties encountered in the assessment were addressed. A high level of confidence would indicate a very low probability that significant new data will be found to overturn the conclusion.

The most convincing evidence that a PRRTP is likely to reduce risk would be clear evidence of changes in exposure and biological effects that indicate reduced risk for all three diseases (LC, COPD, and CVD). When inconsistent conclusions exist or risk is decreased for some of the diseases but increased for others, additional analyses will be necessary to clarify the net effect on risk for continuing smokers using the PRRTP.

To demonstrate the kinds of analysis and information that will be included in the risk characterization, LSRO developed summary data for a hypothetical PRRTP and derived possible weight of evidence conclusions and confidence ratings for each disease/endpoint (Table IV-3). In this example, the data presented support the following overall summary statement: “The hypothetical PRRTP is anticipated to reduce the risk of LC but does not appear to increase or decrease the risk of COPD or CVD.”

Completion of the risk assessment marks a transition in the evaluative/ decision-making process. Up to this point, the process has been primarily science-driven. In contrast, the decision-making (i.e., risk management) phase is informed by science but is primarily policy-driven. The decision- making process for PRRTP is discussed in the final chapter of this report.

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Comparative Risk Assessment 75 based on high evidence of reduced adverse effects in animal and human studies, the degree of reduction, and strong evidence of significantly reduced exposure to carcinogens Risk characterization Confidence that risk of LC is reduced is 0% in short-term assays 9 . Evidence that adverse

effects were reduced was obtained in multiple clinical studies of several biomarkers associated with cancer development in smokers; the biomarkers were consistently reduced by 40 to 70% in PRRTP users Mutagenicity and cytotoxicity were reduced by One long-term carcinogenicity study in rats showed significant decreases in tumors of all sites in animals exposed to the PRRTP emissions Clinical studies showed significant reductions in urine mutagenicity and in several genetic biomarkers of effect associated with cancer development; the magnitude of reductions seen ranged from 40 to 70% Conclusion 0%, depending 9 . Exposure to carcinogens on the chemical Conclusion Exposure assessment LC Large, statistically significant reductions were seen in all classes of potential carcinogens in chemistry studies Biological effects assessment Biomarkers of exposure to nicotine and all categories of potential carcinogens were decreased in several clinical studies; the magnitude of reductions seen was consistent across studies and ranged from 50 to was consistently reduced in users of the PRRTP; reductions were statistically significant and of sufficient magnitude to indicate the potential for reduced risk Table IV-3. Sample of Risk Characterization Summary IV-3. Table

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continued . Evidence of reduced risk for COPD was seen in preclinical and clinical studies; however, the lack of statistical significance in clinical studies and absence of a demonstrated dose-response weaken the confidence in this evidence Short-term cytotoxicity studies show decreased toxicity One 13-week inhalation study in rats shows decreased inflammation and decreases in other adverse effects on upper respiratory tissues Pulmonary function tests show improvement and inflammatory responses are decreased when PRRTP is used for 3 months Number of subjects in the three clinical studies was low (8–10/study). Clinical results were not statistically significant but tended toward values seen in nonsmokers Conclusion . Evidence that exposure to Exposure assessment COPD Chemistry studies show consistent, statistically significant reductions in nicotine and several classes of toxic chemicals that may be related to COPD development; no increases Biological effects assessment were seen Clinical biomarker studies show Risk characterization consistent statistically significant reductions in nicotine and the same toxic chemical classes; no increases were seen Magnitude of decrease varies among and within chemistry biomarker studies for individual chemicals Conclusion toxic chemicals potentially associated with COPD is reduced for the PRRTP was consistently seen in several clinical studies; the magnitude of decrease ranged between 5 and 25% Table IV-3. Sample Risk Characterization Summary ( IV-3. Table

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continued . Clinical studies showed 0-day inhalation study in rats 9 : cardiovascular disease; disease; cardiovascular : showed no adverse effects on cardiovascular system Several well conducted clinical studies showed mixed results in biomarkers of effect. Levels several biomarkers were significantly improved in individuals using the PRRTP over a 12-month period compared to those using a conventional cigarette; others were unchanged or increased Conclusion One evidence of improvement in several biomarkers of effect associated with CVD; however, the finding that others were unchanged or showed small changes indicative of increased risk weakens the confidence in this evidence CVD . No reductions in exposure : chronic obstructive pulmonary disease; chronic obstructive pulmonary disease; : Exposure assessment Biological effects assessment Risk characterization CVD Chemistry studies show consistent, statistically significant reductions in nicotine; however, other potential CVD toxicants were either unchanged or slightly increased (increases were not statistically significant) Several well conducted clinical biomarker studies show consistent, statistically significant reductions in nicotine; other potential CVD toxicants were unchanged or slightly increased Conclusion to possible CVD toxicants (with the exception of nicotine) were seen Table IV-3. Sample Risk Characterization Summary ( IV-3. Table COPD

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IV.5 CONCLUSIONS AND RECOMMENDATIONS Statistically and biologically significant decreases in biomarkers of exposure in individuals using a PRRTP versus conventional cigarettes are direct evidence that exposure reductions are likely to occur in PRRTP users, and indirect evidence that disease risks may be decreased.

Statistically and biologically significant changes in biomarkers of effect that indicate decreased risk of disease in individuals using a PRRTP compared to conventional cigarettes provide evidence that the risks for LC, COPD and/or CVD are likely to be decreased for PRRTP users.

Consistent findings across disease categories support the greatest confidence in overall conclusions. Inconsistent findings require further evaluation to determine whether use of a PRRTP will result in an overall decrease in risk. Even if a net decrease is anticipated, inconsistent findings will significantly complicate risk management decisions related to marketing and use of health-related claims.

The findings and conclusions in the assessment should be reported in sufficient detail for individuals involved in the evaluation process (e.g., peer reviewers) to understand the conclusions and the deliberative process used to reach them. Overall confidence in the risk assessment is increased if it has been independently reviewed by qualified experts. The written report should facilitate the appropriate application of the findings to the decision- making (“risk management”) process.

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V.2 COMPONENTS OF POSTMARKETING EVALUATION

V.3 CLINICAL STUDIES OF EXPOSURE AND EFFECT

V.4 BEHAVIORAL ASSESSMENTS V.4.1 Unintended Users V.4.1.1 Initiation V.4.1.2 Cessation V.4.1.3 Relapse V.4.2 Study Participants V.4.2.1 Never-smokers V.4.2.2 Early initiators V 4.2.3Failed initiators V.4.2.4 Current smokers V.4.2.5 Ex-smokers V.4.3 Study Methods V.4.3.1 Surveys and questionnaires V.4.3.2 Assessment of relative preference V.4.3.3 Abuse liability testing V.4.3.4 Cessation assessment V.4.3.5 Evaluation of consumer perceptions and associated behavior V.4.3.6 Neuroimaging V.4.3.7 Modeling population effects

V.5 SURVEILLANCE AND EPIDEMIOLOGIC STUDIES

V.6 CONCLUSIONS AND RECOMMENDATIONS

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 80 Evaluation of Potential Reduced-Risk Tobacco Products POPULATIONV RISK ASSESSMENT Within the context of tobacco harm reduction and use of potential reduced- risk tobacco products (PRRTP), the term ‘population risk’ generally refers to risk to the “population in the aggregate” or the “overall population” (Institute of Medicine, 2001). The net effect of a PRRTP on population risk is determined by the degree to which risk is decreased for smokers who can not or will not stop smoking (intended PRRTP users) and the degree to which risk is increased for individuals who otherwise would be tobacco free (unintended PRRTP users). Premarketing methods to evaluate reduced risk for intended users were described in the preceding chapters.

V.1 INTRODUCTION Life Sciences Research Office (LSRO) reviewed a wide range of testing and assessment methods, to evaluate increased risk for unintended users. In general, LSRO concluded that the state-of-the-science for premarketing assessment of potential increases in risk for tobacco free individuals is insufficient. While some analyses for potential adverse population effects might be conducted prior to marketing a PRRTP, currently available methodologies do not support quantitative predictions. Therefore, LSRO concluded that postmarketing studies will be necessary to obtain adequate and reliable data to assess adverse population effects of PRRTP use.

Postmarketing evaluation (PME) of PRRTPs includes clinical studies of exposure and effect, behavioral studies, and surveillance and epidemiological studies. Studies of population effects involve assessing tobacco use behavior such as the rate of uptake, maintenance, cessation, and relapse as the result of the introduction of PRRTPs, and the effects of product use on mortality and morbidity.

Design and implementation of a comprehensive PME program that provides information on product characteristics, environmental influences, relevant perceptions and behaviors, biological exposures, and health outcomes will maximize feedback potential and permit corrective action (Hatsukami et al., 2005a). Principles of public health surveillance that should be applied to the monitoring and evaluation of PRRTPs include the ongoing,

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systematic collection, analysis, interpretation, and dissemination of data. An active (rather than passive)13 surveillance system is needed to assess the impact of a PRRTP on a population (Institute of Medicine, 2001).

V.2 COMPONENTS OF POSTMARKETING EVALUATION A PME includes: • Clinical studies to determine whether use of a PRRTP results in reduced exposure and biological effects associated with smoking- related diseases; • Studies of the behavior of smokers or tobacco-free individuals to determine whether PRRTP availability significantly affects rates of initiation, cessation, and/or relapse; • Ongoing surveillance of tobacco use patterns to determine if availability of a PRRTP affects tobacco use prevalence; and • Epidemiological studies to determine if use of a PRRTP reduces overall morbidity and mortality.

A PME program should address both on an individual and population basis, factors that determine the net effect of a PRRTP on population risk. The overall effect on the population will depend on the number of intended users who switch to a reduced-risk product and the degree to which their risk is reduced, minus the number of unintended users who use the product and the degree to which their risk is increased.

V.3 CLINICAL STUDIES OF EXPOSURE AND EFFECT Clinical studies like those used in premarketing assessments will determine short-term effects of PRRTP on exposure and risk for intended users under actual conditions of use. Study details have been discussed in Chapter III and are not repeated here.

V.4 BEHAVIORAL ASSESSMENTS Behavioral studies of potential changes in tobacco use can provide information on the likelihood that unintended users would use a PRRTP.

13 An example of an active surveillance system is a survey conducted to assess health status and/or high-risk behaviors (such as cigarette smoking). Passive surveillance depends on third party (e.g., health providers) voluntarily reporting of adverse events.

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V.4.1 Unintended Users There are three categories of unintended PRRTP users: never-smokers; current smokers with a proximate intent to quit; and ex-smokers. For never smokers, the major issue is initiation. If a PRRTP is available, is an individual significantly more likely to start smoking than they would have been in its absence? For current smokers with a proximate intent to quit, the concern is cessation. Will current smokers (who have indicated intentions of quitting in the near-term) switch to a PRRTP and eliminate or postpone their planned attempt to quit? For ex-smokers, the concern is relapse. Will the availability of a PRRTP increase the relapse rate in ex-smokers?

V.4.1.1 Initiation Research on smoking initiation has shown that never-smokers occupy a continuum (Choi et al., 2001; Conrad et al., 1992; Pierce et al., 1996; Tyc et al., 2004; van den Bree et al., 2004; Virgili et al., 1991). At one end of the continuum are individuals who are strongly opposed to tobacco use, and the rate of initiation of tobacco use among them is very low. At the other end of the continuum are people who admit that they are curious about tobacco use and that they are likely to try a tobacco product in the near future (Choi et al., 2001). Initiation of tobacco use among the latter group occurs at a much greater rate than among those unambiguously opposed to tobacco use (Choi et al., 1997; Choi et al., 2001). In the middle of the continuum, people have a range of attitudes, giving rise to different rates of initiation (Choi et al., 2001; 2003; Kremers et al., 2001; Social Sciences Data Collection, 2005).

Most smokers begin to smoke in their mid-teens and eventually become daily smokers (Audrain-McGovern et al., 2004). Many factors influence or affect a person’s decision to begin smoking, including: parental/peer smoking, trouble in school/rebelliousness, risk-taking behaviors, depression, poor family situations, receptiveness to tobacco advertising, and low socioeconomic status (Audrain-McGovern et al., 2004; Conrad et al., 1992; Droomers et al., 2005; Gilpin et al., 2005; Gritz et al., 2003; Mowery et al., 2004; Pierce et al., 1996; Tercyak, 2003; Tyas & Pederson, 1998; Tyc et al., 2004).

V.4.1.2 Cessation Because conventional cigarettes are particularly effective in creating and sustaining nicotine dependence, cigarette use is highly habituating (National Institute on Drug Abuse, 2006). Fast delivery of nicotine to the brain is critical to that dependence and after absorption in the lungs, nicotine is delivered

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to the brain within 10–15 seconds of smoke inhalation (Haussmann, 2000). Such rapid delivery creates a very effective behavioral reinforcement for smoking (Benowitz, 1998).

Studies using denicotinized cigarettes report comparable satisfaction levels to those reported smoking nicotine-containing cigarettes, at least in the short term, with the act of smoking a nicotine-free cigarette exhibiting an apparent placebo effect of suppressing nicotine withdrawal (Buchhalter et al., 2001). Sensory cues, which can contribute to the difficulties associated with quitting, can also help to reduce craving (Rose & Behm, 2004; Rose et al., 1993; Westman et al., 1995; 1996).

V.4.1.3 Relapse Ex-smokers have abstained from smoking for an extended period of time. Guidelines recommend that quit attempts be followed for at least six months to determine successful abstinence rates (Hughes et al., 2003; Pierce & Gilpin, 2003). Those who successfully quit smoking tend to be older, of higher income, and have smoking behaviors indicating a lower degree of dependence (as indicated by measures like time to first cigarette, or cigarettes smoked per day) than those who do not successfully quit (Falba et al., 2004; Gilpin & Pierce, 2002; Hyland et al., 2004; Lemmonds et al., 2004). Those who quit successfully often have greater access to resources that aid in cessation, including medical, environmental (such as non-smoking workplaces), and supportive family and friends (Hughes, 2003; Ling & Glantz, 2004).

V.4.2 Study Participants Based on the behaviors of interest (initiation, cessation, and relapse) and the subpopulations in which these occur, the subjects to be included in the behavioral evaluations described in the next section are never-smokers, early initiators, failed initiators, current smokers, and ex-smokers.

V.4.2.1 Never-smokers A never-smoker cannot be tested in clinical studies of behavior; however, they can participate in surveys comparing the attractiveness of a PRRTP to conventional cigarettes to help determine if initiation may increase.

V.4.2.2 Early initiators An early initiator has just begun using some form of tobacco. LSRO defined early initiators as people who had smoked 0–50 cigarettes over a relatively

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short time period. These individuals are experimenting with tobacco use. Because they are already using cigarettes, early initiators are potential subjects for clinical behavior assessments.

V.4.2.3 Failed initiators A failed initiator has smoked between 50 and 100 cigarettes (or equivalents) over an extended period of their life, but has not become a habitual smoker. LSRO considers these people unlikely to become regular tobacco users. Failed initiators are not appropriate for clinical assessment because they do not smoke; however, a survey of their attitudes towards a PRRTP could provide useful information about the relative appeal (and potential to increase initiation) of a PRRTP and conventional cigarettes.

V.4.2.4 Current smokers Current smokers can be divided into several categories: dependent smokers with a proximate intention to quit, dependent smokers without a proximate intention to quit, ‘chippers’, and occasional smokers.

Smokers with a proximate intention to quit have expressed a desire to quit within 30 days. The effect of a PRRTP on quit rates for this group is especially important because they are the smokers most likely to attempt to quit. Smokers with no proximate intention to quit are the intended users of PRRTP and, at most, could serve as controls in certain studies and/or surveys. Chippers are individuals who smoke several cigarettes per day, 2–3 times a week, but do not increase amount or frequency and do not meet the criteria for nicotine dependence (Shiffman, 1989; Wellman et al., 2006). This group, also divided by intention to quit, would be appropriate for clinical assessment. Finally, occasional smokers are “situational” smokers; they usually smoke in social settings. They smoke less frequently than chippers and are not nicotine dependent.

V.4.2.5 Ex-smokers Ex-smokers are individuals who have abstained from smoking for more than six months. Because it would be inappropriate to conduct clinical assessments on ex-smokers, smokers who are experiencing induced nicotine withdrawal (nicotine-deficit individuals) could act as surrogates for ex-smokers. Ex-smokers, however, could be surveyed regarding their attitudes toward a PRRTP.

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V.4.3 Study Methods V.4.3.1 Surveys and questionnaires Recent publications have shown that well defined surveys can be used to identify groups with a high likelihood of tobacco initiation (Lewis-Esquerre et al., 2005; Tyc et al., 2004; Wakefield et al., 2004). At least in principle, survey questions could be used to assess attitudes and, more importantly, changes in attitudes, when an individual is asked to compare the likelihood that he/she will try a conventional cigarette with the likelihood of trying a PRRTP. The survey should include questions about the specific characteristics of a PRRTP to ascertain which characteristics may increase the likelihood of initiation such as: peer/social acceptance of the PRRTP, relative cost, and the degree to which evidence of use can be concealed. Surveys should try to capture these characteristics by including questions related to the PRRTP’s relative price, probable availability, and the odor, visibility and other relevant aspects of sidestream and environmental tobacco smoke. Surveys including marketing information, such as proposed claims, would also be of use. Survey design and question development should be supervised/reviewed by experienced survey design professionals.

Survey populations could include any of the groups described above; however, some subgroups of smokers can only be studied using these approaches. For example, 14–16 year olds are particularly vulnerable to becoming daily smokers, who presumably are nicotine-dependent (Audrain- McGovern et al., 2004; Breslau et al., 1993). These smokers are too young to legally use tobacco or to give the informed consent required to participate in clinical studies.

V.4.3.2 Assessment of relative preference In preference testing, participants are presented various options, each of which can be accessed or avoided by some method, such as a key press. The cost of each option can be adjusted by making it require more effort to access or avoid a particular item (Johnson & Bickel, 2003; Johnson et al., 2004; Shahan et al., 2000; Solomon & Corbit, 1973, 1974). Using this technique the relative preferences of a large number of never-smokers, occasional smokers, and dependent smokers can be assessed for a variety of relevant options before and after marketing a PRRTP. To increase understanding of the responses, a subset of these test subjects can undergo neuroimaging to assess brain responses to the various options (see Section V.4.3.6).

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V.4.3.3 Abuse liability testing Abuse liability is the potential for abuse of and increased addiction to a tobacco product. It is affected by environmental (e.g., availability, legality, social sanctions), organic (e.g., individual susceptibility, personality, genetics), and pharmacological (e.g., sites of action, rates of onset, duration of effects) factors (Henningfield & Keenan, 1993).

Nicotine pharmacokinetics has been used to test the abuse liability of tobacco products (Benowitz et al., 1988; Benowitz, 1998; Fant et al., 1999). Tobacco products causing the greatest and most rapid increases in blood nicotine may be associated with greater addiction potential (Henningfield & Keenan, 1993). Previous experience with reduced-yield cigarettes has shown that it is critical to test the device’s ability to deliver nicotine under actual use conditions (Wayne et al., 2006; Gendreau & Vitaro, 2005).

V.4.3.4 Cessation assessment Multiple measures are available to assess cessation motivation and progress: • Motivation to quit (Biener & Abrams, 1991; Carpenter et al., 2003; Etter et al., 2002; Fagerström, 2000; Hatsukami et al., 2005a,b); • Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Composite International Diagnostic Interview (section on smoking behavior) for comorbid psychiatric disease(s) that will affect smoking cessation (Schumann et al., 2004); • Cessation progression as time to a quit attempt (Etter et al., 2002; Hatsukami et al., 2005a; Prochaska et al., 1992); • Number of quit attempts (Bolliger et al., 2000; Carpenter et al., 2003; Hatsukami et al., 2005a); • Duration of abstinence (Hatsukami et al., 2005a); and • Comparison of abstinence rates associated with a PRRTP and conventional cigarettes (Hatsukami et al., 2005a).

V.4.3.5 Evaluation of consumer perceptions and associated behavior Another important determinant of smoking behavior is an individual’s attitude toward and perception of the risks of smoking (Slovic, 2001). For example, Weinstein (1987, 1998, 2001) and others (Sutton, 1999; Viscusi, 1992) have demonstrated that “optimism bias”, where people see themselves as being at less risk than their peers to the same hazards, is independent of age, sex, educational, or work status, can minimize appropriate responses to risk-based messages.

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Differences in risk perception and associated smoking behaviors have been identified between young people (14–22 year olds) and adults (≥ 23 years old) (Romer & Jamieson, 2001a). Young people appear to disregard the risks of smoking even when they have a heightened perception of risk and tend to overestimate the ease of quitting (Jamieson & Romer, 2001a). Therefore, they perceive themselves to be at little or no risk because they expect to stop smoking before any adverse health effects could develop (Slovic, 2001). Perceptions of risk play a much larger role for adults, who were found to reduce their smoking as their perceptions of risk increased (Romer & Jamieson, 2001a). Interestingly, adults who choose never to smoke do not base the decision on perceived health risks but rather on unfavorable feelings about smoking.

There is an inverse relationship between the effect of risk perception and the effect of positive feelings about smoking on smoking behavior. As positive feelings increase the influence of risk perception on smoking decisions diminishes. Positive feelings about smoking are often facilitated by advertising, which shows favorable images of smokers, and smoking, and other brand marketing methods such as promotions and giveaways (Romer & Jamieson, 2001b).

The effect on smoking behavior of adding a reduced-risk claim to product advertising and other marketing methods has not been directly assessed. However, several factors that tend to decrease concerns about risk could combine to have a significant effect on the incidence of smoking in a population. Therefore, LSRO recommends including marketing messages, health-related claims, and actual imagery of product packaging and advertisements for a PRRTP in PME surveys and behavioral studies used to assess attitudes, preferences, and tobacco use behavior. To the extent that such information is available prior to marketing, it should be incorporated in premarket assessments of PRRTPs.

V.4.3.6 Neuroimaging McClernon and Gilbert (2004) reviewed results of brain neuroimaging in nicotine and tobacco research for: neurochemistry, smoking and nicotine administration, craving and cue reactivity, cognitive and affective information processing, and tobacco withdrawal and concluded that functional neuroimaging is a useful tool.

Neuroimaging can be coupled with self-reported information about tobacco attitudes and behavior to provide quantitative information (see Section V.4.3.5). The quantitative, reliable, and replicable nature of neuroimaging

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results could improve the predictive value of surveys and behavioral studies of the most vulnerable populations for smoking initiation (e.g., populations with comorbid disorders and low socioeconomic/less-educated populations) and cessation (e.g., populations of individuals with a proximate intent to quit). Surveys coupled with a neuroimaging technique like functional magnetic resonance imaging could be conducted before and after the launch of a marketing campaign to assess the impact of PRRTP marketing and health-related claims.

V.4.3.7 Modeling population effects Simulation models developed for premarketing use can provide insight into certain behaviors not captured by the types of studies described above (e.g., progression from a PRRTP to a riskier product (i.e., conventional cigarettes), a phenomenon known as the gateway effect (Tomar, 2003).

Models can include variables like price and taxes not addressed by the Reduced Risk Review Project, and can assess the potential for interaction between the various factors and the effect on overall population risk. Models that have been applied to tobacco harm reduction include the Tobacco Policy Model, which is designed to calculate public health gains or losses from any change in the hazards associated with or patterns of cigarette use (Tengs et al., 2004), and computer simulation models to assess the impacts of various tobacco control policies (Ahmad & Billimek, 2005; Levy et al., 2002).

V.5 SURVEILLANCE AND EPIDEMIOLOGIC STUDIES Numerous state and federal surveys monitor tobacco-related variables (Institute of Medicine, 2001). However, no single survey assesses tobacco use behaviors, risk perceptions, and tobacco-attributable morbidity and mortality. Thus, a combination of behavioral, epidemiologic, and clinical methods will be needed to determine the effects of a PRRTP within a defined population of smokers, ex-smokers, and never smokers.

Typical postmarketing surveillance methods (i.e., for drugs, devices) are passive and produce anecdotal data based on reporting from healthcare professionals or self-reports. They are inadequate to assess PRRTP-related population effects. Randomized controlled studies are necessary to examine possible associations of reported effects with PRRTP use. Surveillance data, however, may help identify unanticipated adverse effects associated with a PRRTP. For example, PRRTP that vaporize tobacco could be adapted to deliver other substances (e.g., household chemicals, illegal drugs), which would result in increased harm to the individuals who use them this way.

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Epidemiological studies, such as cohort or case-control studies, are necessary to determine whether PRRTP users have lower incidence of and mortality from lung cancer, chronic obstructive pulmonary disease, cardiovascular disease, and other smoking-related diseases than users of conventional cigarettes. These studies must be of sufficient statistical power and adequately controlled to account for potential confounding factors, including the subjects’ socioeconomic status, occupational history, age, sex, and gender.

Although methods to assess behavioral, exposure, and biological effects are improving, intra- and inter-individual genetic, metabolic, and biological variability and differences in active and passive smoke exposure from different tobacco products (and various combinations of these and other factors) will have a marked effect on the ability to identify “real” differences in individual and population risk associated with a PRRTP.

V.6 CONCLUSIONS AND RECOMMENDATIONS LSRO concluded that a combination of clinical, behavioral, and epidemiologic methods is needed to determine the effects of a PRRTP on population risk. While some analyses aimed at understanding population impacts may be conducted prior to marketing a PRRTP, the most useful data will be generated after the product has entered the market place.

Postmarketing evaluation is necessary to assess the net effect of a PRRTP on population risk, which includes measuring the degree of risk reduction in PRRTP users and the impact of PRRTP-availability on overall tobacco use. Appropriate controlled clinical studies of exposure and effect in intended users, and behavioral assessments and surveys of tobacco use and attitudes in unintended users, can provide early indicators of population effects of a PRRTP. Despite the availability of different PME approaches, implementing a scientifically sound program capable of detecting positive and negative effects in a timely fashion is challenging. LSRO recommends assigning a high priority to development of better tools to assess potential adverse population effects.

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VI.1 INTRODUCTION

VI.2 CURRENT TOBACCO CONTROL POLICIES ON SMOKELESS TOBACCO PRODUCTS VI.2.1 Definition of Smokeless Tobacco Products VI.2.2 Smokeless Tobacco and Risk Reduction: Scientific Evidence VI.2.3 Smokeless Tobacco and Risk Reduction: Public Policies VI.2.3.1 World Health Organization VI.2.3.2 European Union VI.2.3.3 United States

VI.3 VALIDITY TOBACCO CONTROL POLICIES VI.3.1 Scientific Validity VI.3.2 Ethical Validity

VI.4 DISCUSSION

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SCIENCE AND POLICY IN PRRTP DECISIONVI MAKING VI.1 INTRODUCTION The findings, conclusions, and recommendations presented in the preceding chapters fully address the Reduced Risk Review Project (RRRP) objective to develop a science-based approach to the assessment of potential reduced-risk tobacco products (PRRTPs).

Although the RRRP focused on scientific considerations in PRRTP decision making and not on policy recommendations, Life Sciences Research Office (LSRO) recognizes that science does not occur in a vacuum. The acceptance and use of scientific information in public health decision making is influenced by a number of factors, including relevant public policies.

This chapter includes a brief review of tobacco control policies that are relevant to PRRTPs. This review is followed by a discussion of the potential impact of current policies on PRRTP decision making and public health.

VI.2 CURRENT TOBACCO CONTROL POLICIES ON SMOKELESS TOBACCO PRODUCTS In this section, LSRO briefly reviews current policies on smokeless tobacco (ST)14 products, which reflect the widespread opposition to the inclusion of PRRTPs in tobacco control. US and other tobacco control policies are abstinence-based and have had this focus since the late 1970s (Parascandola, 2005). As LSRO noted earlier in this report, complete abstinence from tobacco product use in general and from cigarettes in particular is best. For those who already use tobacco products, the best action is to quit immediately. Other approaches to tobacco control, such as tobacco harm reduction (THR), have been recommended to augment abstinence-based policies and programs (Institute of Medicine, 2001). THR approaches are controversial, especially if they involve continued use of tobacco products of any kind, at any level (Gray and Henningfield, 2006).

14 LSRO considers ST products a type of PRRTP.

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VI.2.1 Definition of Smokeless Tobacco Products ST products do not require combustion to be used (World Health Organization Scientific Advisory Committee on Tobacco Products Regulation, 2003); rather, ST, which is also referred to as “oral” or “spit” tobacco, is sniffed, dipped, or chewed, according to the tobacco type and constitution (Institute of Medicine, 2001). Oral use is by far the most common, and nasal use is very rare (World Health Organization Scientific Advisory Committee on Tobacco Products Regulation, 2003). The most commonly used ST products in the US are moist snuff and chewing tobacco.

VI.2.2 Smokeless Tobacco and Risk Reduction: Scientific Evidence Health risks are associated with ST (World Health Organization Scientific Advisory Committee on Tobacco Products Regulation, 2003), including oral and pancreatic cancers (International Agency for Research on Cancer, 2004b), noncancerous oral and periodontal disease, tooth decay, and pregnancy-related health problems (NIH State-of-the-Science Panel, 2006).

However, epidemiological evidence has also demonstrated that the risk of dying from a tobacco-related disease is significantly lower (between 10 and 1000 times lower) for users of snus in Sweden and users of moist snuff in the US15 for smokers of conventional cigarettes (Levy et al., 2004; Tobacco Advisory Group of the Royal College of Physicians, 2002; Savitz et al., 2006).

VI.2.3 Smokeless Tobacco and Risk Reduction: Public Policies The critical policy debate centers on whether cigarette smokers who will not or can not quit and who do not use nicotine replacement therapy should be informed that switching completely to ST will reduce their risk of smoking- related diseases. The following sections describe policies on ST use to reduce the risks associated with cigarette smoking.

VI.2.3.1 World Health Organization The World Health Organization (WHO) Study Group on Tobacco Product Regulation (TobReg) addressed the “ongoing debate in the public health community about the potential for smokeless tobacco, especially snus

15 Smokless tobacco products and use patterns are diverse worldwide. Smokeless tobacco products from various regions include: mixed betel quid and tobacco and tobacco and lime in South Asia; toombak in Sudan and other African countries; shammah in Saudi Arabia; and nass and nasswaris in Central Asia republics (World Health Organization Scientific Advisory Committee on Tobacco Products Regulation, 2003).

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manufactured in Sweden, to be used as a substitute for smoking as part of a harm reduction strategy.” (World Health Organization Scientific Advisory Committee on Tobacco Products Regulation, 2003).

TobReg concluded that: “[T]here is no evidence to recommend that any smokeless tobacco product should be used as part of a harm reduction strategy. Marketing of smokeless tobacco products with harm reduction claims should not be permitted unless validated by an independent regulatory authority on review of evidence to be submitted by the manufacturer.” It also noted that “[t]he designation of smokeless tobacco products as harm reducing agents may promote a false perception of safety. A lower risk of adverse health outcomes is achieved by reducing smoking and not by substituting another form of tobacco use.”

VI.2.3.2 European Union With the exception of Sweden, the sale of ST products is not permitted in the European Union (EU). The EU ban was enacted to protect public health by preventing people from starting to use a new tobacco product and to ensure proper functioning of the Internal Market (three Member States had already adopted such bans) (European Economic Commission, 1992, 2006). Recent review of this policy in light of the “Swedish experience” (European Network for Smoking Prevention, 2005) supported retention of the EU ban because (1) declines in lung cancer mortality seen in Swedish men cannot be directly attributed to their preference for snus compared to smoking; (2) projected lung cancer declines in other countries, such as the UK, where ST is not widely used, will soon equal those seen in Sweden; (3) ST is not risk-free; and (4) ST use can be a gateway to smoking.16

VI.2.3.3 United States The US Public Health Service has concluded that scientific evidence is insufficient “to endorse any tobacco product, including smokeless tobacco, as a means of reducing the risks of cigarette smoking. … [Additional data are needed on] the risks to individuals of switching from smoking to smokeless; and we need to know more about the risks to the entire population of a promotion campaign that would position smokeless tobacco as a safer substitute for smoking” (Carmona, 2003). A state-of-the-science panel convened by the National Cancer Institute to address population-based

16 The EU Directorate General for Health and Consumer Affairs recently began a review of the scientific basis for the current regulatory framework. Specifically, it has requested the Scientific Committee on Emerging and Newly Identified Health Risks for its opinion on the health effects of ST products (European Public Health Alliance, 2006).

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strategies for tobacco use prevention and cessation considered the impact of ST marketing and use on population harm (National Cancer Institute, 2006). The panel identified three reasons for concern: (1) ST is associated with numerous health risks; (2) there are limited data about the effect of ST on public health; and (3) aggressive marketing may increase ST use in the US.

VI.3 VALIDITY OF TOBACCO CONTROL POLICIES Scientists and policy specialists within the tobacco control community have examined the scientific and ethical validity of the preceding policies on ST and tobacco harm reduction.

VI.3.1 Scientific Validity There is extensive scientific evidence that risk is reduced in individuals who use ST: “Even allowing for cautious assumptions about the health impact, snus and other oral tobacco are a very substantially less dangerous way to use tobacco than cigarettes” (Bates et al., 2003). In contrast, the evidence for adverse population effects of ST (i.e., increased use of tobacco products) is inconsistent and no consensus has been reached (NIH State-of-the- Science Panel, 2006). Furthermore, the risk differential between ST (especially snus) and cigarettes is so great that net societal harm due to increases in tobacco product use is very unlikely (Kozlowski et al., 2003).

VI.3.2 Ethical Validity Ethical concerns have focused on the need to provide accurate scientific information concerning the relative risks of ST and cigarettes and on the balance between individual human rights and public health considerations. For example, Kozlowski and Edwards (2005) challenged the message that there is “no safe cigarette” or “no safe tobacco product” as “so limited in its value that it represents a violation of the right to health relevant information.” The authors concluded that “[t]his right should be respected whether or not harm reduction policies are judged advisable” and pointed out that the American Public Health Association’s position on individual human rights and public health goals states that human rights must not be sacrificed to achieve public health goals except in extraordinary circumstances (Koslowski & Edwards, 2005).

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. Science And Policy In PRRTP Decision Making 95 VI.4 DISCUSSION As challenging as the science needed to adequately assess PRRTPs is, rethinking a policy active for 30 years is, in many ways, much more difficult. Nevertheless, calls to reexamine current policies have increased in recent years. Several factors contribute to the interest in expanding tobacco control policies beyond encouraging/supporting abstinence, including the high number of individuals who continue to smoke, low success rates for smoking cessation, changes in smoking demographics, the continued high numbers of deaths due to active and/or passive smoking in developed nations, and significant increases in cigarette smoking worldwide.

Adherence to current policies has resulted in well established scientific information concerning the relative risks of using a PRRTP (ST) and smoking cigarettes being withheld from individuals who could benefit from this information. This means that the individuals at greatest risk of dying from diseases caused by cigarette smoking—current smokers who can not or will not quit smoking—may remain unaware of actions they could take to reduce their risk of dying prematurely. These policies subordinate the known harms experienced by smokers to hypothetical increases in population risk. As noted above, public health concerns should supercede individual rights only when there is clear and convincing evidence of harm to society. Lacking that evidence, individual rights should prevail (Kozlowski et al., 2003).

A strong case could be made that current abstinence-based policies are no longer sufficient to reduce the toll of cigarette smoking on public health: although the incidence of smokers continues to decrease, the number of adult smokers has remained constant in the US for over a decade. Current smokers are more likely to have fewer resources to help them quit and are more likely to suffer co-morbidities, such as mental disease, that decrease their likelihood of achieving abstinence. New tools and approaches are needed to achieve the greatest good. Decisions that are made concerning inclusion of PRRTPs in tobacco control programs could well be decisions of whether some good is better than none at all.

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The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. APPENDICESVIII VIII.A LIFE SCIENCES RESEARCH OFFICE (LSRO) VIII.A.1 Reduced Risk Review Project Core Committee Alwynelle (Nell) Ahl, Ph.D., DVM Nell Ahl is Principal Scientist at Highland Rim Research Consulting, Inc. (HRRC). After majoring in biology and mathematics at Centenary College of Louisiana, she obtained her M.S. and Ph.D. in zoology and biochemistry from the University of Wyoming, and a doctorate in veterinary medicine from Michigan State University where she also served as a Professor in the Department of Natural Science. Prior to her work at HRRC, Dr. Ahl had a distinguished career at the U.S. Department of Agriculture (USDA) serving in various capacities, including Deputy Director for Animal Health Training and Chief of Risk Analysis Systems within USDA’s Animal and Plant Inspection Service. She also served in the Senior Executive Service as the first Director of the USDA Office of Risk Assessment and Cost-Benefit Analysis and as an USDA Fellow to the Center for the Integrated Study of Food, Animal and Plant Systems at Tuskegee University in Alabama. She is a fellow of the American Association for the Advancement of Science and has served on several panels at the National Academy of Sciences. Her research interests include public policy for science and veterinary medicine and the use of risk assessment for agricultural issues affecting human health. Dr Ahl’s presentations and publications total more than 250, and she has edited reports from more than a dozen symposia.

Elizabeth L. Anderson, Ph.D., Fellow A.T.S. Elizabeth L. Anderson is Group Vice President of the Health Sciences and Food & Chemicals Division of Exponent and has over 20 years of experience, both government and corporate, in health and the environmental sciences. She received her B.S. in chemistry from the College of William and Mary, her M.S. in organic chemistry at the University of Virginia, and her Ph.D. in organic chemistry at The American University. Formerly, she served as President and Chief Executive Officer of Sciences International, Inc. and was President, Chief Executive Officer, and Chairman of the Board of

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Clement International Corporation (ICFI), where she directed an interdisciplinary group of 200 senior scientists and engineers. She founded and directed the central risk assessment programs at the U.S. Environmental Protection Agency (EPA) for ten years. The primary functions of the office were to conduct risk assessments on the health effects of a wide variety of toxic chemicals, provide leadership to establish EPA-wide guidelines for risk assessment, and oversee EPA’s risk assessment programs. She is the recipient of the EPA Gold Medal for Exceptional Service. Dr. Anderson is an internationally recognized lecturer and consultant and has published numerous journal articles in the areas of risk assessment and carcinogenicity. She is in her sixth year as Editor-in-Chief of Risk Analysis: An International Journal.

Nancy L. Buc, Esq. Nancy Buc is a Partner at Buc & Beardsley, Washington, DC. She received her A.B. from Brown University, her LL.B. from the University of Virginia, and her LL.D. (Honoris Causa) from Brown University. She has taught Food and Drug Law at Georgetown University Law Center and is a Trustee Emeritus of Brown University. She served as Chief Council at the U.S. Food and Drug Administration from 1980-1981. She also served as Attorney- Adviser to Federal Trade Commission Chairman Miles W. Kirkpatrick and as Assistant Director, Bureau of Consumer Protection at the Federal Trade Commission (1969-1972). Ms. Buc has served as a member on various advisory committees and panels to the National Institutes of Health, Institute of Medicine, and Office of Technology Assessment.

Carroll Cross, M.D. Carroll E. Cross, M.D., is Professor of Medicine and Physiology at the University of California, Davis, School of Medicine, where he is an Attending Physician in Pulmonary and Critical Care Medicine. He graduated from Columbia College of Physicians and Surgeons in 1961, completed his internship at the University of Wisconsin Hospital in 1962, his residency at Stanford Hospital Center in 1964, and his clinical and research fellowship training at the University of Pittsburgh Medical Center in 1968. He was certified in internal medicine in 1969 and in pulmonary disease in 1971. Dr. Cross has published over 200 papers in such fields as air pollutants, antioxidant micronutrients, inflammatory-immune system oxidants, ozone, oxides of nitrogen, cigarette smoke, and aspects of inhalation toxicology as it relates to respiratory tract diseases. He is a member of several professional organizations, including the American Physiological Society, the UK Biochemical Society, the Free Radicals in Medicine and Biology Society, the Mount Desert Island Biological Laboratory, the Western Society of

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Physicians, and the American Society for Clinical Nutrition. He serves on the editorial boards of the American Journal of Clinical Nutrition, and Free Radicals in Biology and Medicine, and has served on research review panels for the Veterans Administration, for the National Iinstitutes of Health, and for the Heart, Lung, and Cancer Society Associations.

Louis D. Homer, M.D., Ph.D. Louis D. Homer, M.D., Ph.D., is the former Medical Director of Clinical Investigation and Biomedical Research at Legacy Research, Holladay Park Medical Center, OR. He received his Ph.D. in physiology and his M.D. from the Medical College of Virginia. He has served as Assistant and Associate Professor at Emory University concentrating on physiological processes and mathematical models. Afterward he served as Associate Professor at Brown University and then moved on to become a Research Medical Officer at the Naval Medical Research Institute concentrating on biometrics, physiology, environmental medicine, metabolic research, and kidney transplant histocompatibility. He served as a consultant to scientists regularly on topics ranging from physiology, mathematics, and statistics, to computer application. He also reviewed proposals and served on site-visit teams for National Institute of Allergy and Infectious Diseases, National Heart, Lung, and Blood Institute, National Science Foundation, and the Naval Medical Research and Development Command. He has reviewed prospective articles for the Journal of Theoretical Biology, Microvascular Research, American Journal of Physiology, and the Journal of Applied Physiology. His interest in using mathematical models of physiology in his research has led him to become familiar with a number of computer languages, numerical algorithms, iterative least-square estimation, and iterative maximum-likelihood estimation.

Joseph V. Rodricks, Ph.D., D.A.B.T. Joseph V. Rodricks is a Founder and Principal of ENVIRON Corporation and an internationally recognized expert in the fields of toxicology and risk analysis. Dr. Rodricks received his B.S. in chemistry from the Massachusetts Institute of Technology and his M.S. in organic chemistry and Ph.D. in chemistry from the University of Maryland. Dr. Rodricks was formerly the Director, Life Sciences Division, Clement Associates (1980-1982), the Deputy Associate Commissioner, Health Affairs, and Toxicologist, U.S. Food & Drug Administration (1965-1980), and is a Visiting Professor at the Johns Hopkins University School of Public Health. He has published over 100 peer-reviewed articles and is the author of Calculated Risks (Cambridge University Press), a non-technical introduction to toxicology and risk analysis.

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Richard C. Schwing, Ph.D. Richard C. Schwing is President and Founder of Sustainable Visions, Inc., a firm devoted to the consumer-driven search for more sustainable products and lifestyles. Dr. Schwing received his B.S., M.S., and Ph.D. in chemical engineering from the University of Michigan. Dr. Schwing previously worked in General Motors research and development. His focus areas included highway safety, environmental pollution, and corporate strategy. As a founding member of GM’s unique–in–industry Societal Analysis Department, he developed groundbreaking approaches to air pollution health effects, risk analysis, risk trade-offs, human behavior components of risk, and technology forecasting and societal trends. He has authored several technical papers, and co-authored the paper Interdisciplinary Vision: The First 25 Years of the Society for Risk Analysis (SRA) 1980-2005.

Emanuel Rubin, M.D. Emanuel Rubin is Gonzalo E. Aponte Distinguished Professor of Pathology and Chairman Emeritus of the Department of Pathology, Anatomy, and Cell Biology at Jefferson Medical College Philadelphia, PA. He obtained a M.D. from Harvard Medical School. After completing residency at the Children’s Hospital of Philadelphia, he continued as a Dazian Research Fellow in pathology and as Advanced Clinical Fellow of the American Cancer Society, both at Mount Sinai Hospital in New York. After his fellowship, Dr. Rubin spent fourteen years at Mount Sinai Hospital’s Pathology Service with increasing responsibilities, culminating in Pathologist-in-Chief. Dr. Rubin then became the Director of Laboratories at the Hahnemann University Hospital. His many academic appointments include the Irene Heinz and John LaPorte Professor and Chairman of the Department at Mount Sinai School of Medicine, Professor and Chairman of the Department of Pathology and Laboratory Medicine at the Hahnemann University School of Medicine, Adjunct Professor of Biochemistry and Biophysics at the University of Pennsylvania School of Medicine, and several appointments at Jefferson Medical College, culminating in his current position. Among honors received, the University of Barcelona and the University of Naples named him as Doctor Honoris Causa. He was also given the F. K. Mostofi Distinguished Service Award from the U.S.-Canadian Academy of Pathology and the National Institutes of Health MERIT Award. He has held many editorial positions and has served as a consultant to many organizations. He has more than 300 publications, including 13 textbooks and one CD-ROM.

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Richard Windsor, M.S., Ph.D., M.P.H. Richard Windsor is a Professor in the Department of Prevention and Community Health in the School of Public Health and Health Services at the George Washington University (GWU), Washington D.C., and is a nationally recognized expert in public health program evaluation. Dr. Windsor obtained a B.S. in community health education from Morgan State College, Baltimore, MD, a M.S. and Ph.D. in public health education and educational/ social psychology from the University of Illinois, Urbana-Champaign, and a M.P.H. in maternal and child health from The Johns Hopkins University Baltimore, MD. Prior to joining GWU, he held academic appointments and provided research and management leadership at a number of institutions, including Ohio State University, University of Alabama Medical Center, and The Johns Hopkins University, and has served as Associate Director for Prevention at the National Heart, Lung, and Blood Institute. He served as the Principal Investigator of five and CO-Principal Investigator of three NIH- funded randomized clinical trails to evaluate Smoking Cessation or Reduction in Pregnancy Treatment (SCRIPT) Methods. Dr. Windsor was recognized by the Agency for Healthcare Research Quality (2002) Tobacco Treatment Clinical Practice Guidelines, and received the C. Evertt Koop National Health Award (1997) for his scientific leadership and contributions to the evidence- based treatment of pregnant smokers.

VIII.A.2 State-Of-The-Science Review Committees VIII.A.2.1 Exposure Assessment Committee Richard N. Dalby, Ph.D. Richard Dalby is a Professor in the Department of Pharmaceutical Sciences at the University of Maryland School of Pharmacy. He holds a Bachelor of Pharmacy degree (1983) from Nottingham University in England, and a Ph.D. in pharmaceutical sciences from the University of Kentucky (1988). Dr. Dalby’s aerosol research, which encompasses novel pulmonary and nasal formulation development, device design, and product testing, is founded on his Ph.D. work on sustained release metered dose inhalers, and industrial experience as a Formulation Scientist from 1988-1989 with Fisons (now Aventis). He has published more than 40 papers and 90 abstracts related to aerosol technology, authored several book chapters, and spoken at many national and international meetings. He holds three patents concerned with novel MDI formulations, is a reviewer for many international journals, and is a frequent consultant to industry and FDA. Dr. Dalby is the director of the Inhalation Aerosol Technology Workshop that is taught annually in Baltimore and at company facilities worldwide, and co- organizer and editor of Respiratory Drug Delivery, and its spin-off, RDD

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Europe. Dr. Dalby is a Dean’s Distinguished Educator at the University of Maryland School of Pharmacy and a Fellow of the American Association of Pharmaceutical Scientists.

Karl-Olav Fagerström, Ph.D. Karl Fagerström graduated from the University of Uppsala as a licensed clinical psychologist in 1975. At that time, he started a smoking cessation clinic. In 1981, he earned his Ph.D.; his dissertation examined nicotine dependence and smoking cessation. In the late 1970s and early 1980s, he served as the Editor–in–Chief for the Scandinavian Journal for Behaviour Therapy. From 1983 through 1997 he worked for Pharmacia & Upjohn as Director of Scientific Information for Nicotine Replacement Products. He has contributed to NRT developments such as nicotine gum, patch, spray, and inhaler. He currently works in private practice (Fagerström Consulting and the Smokers Information Center). He is a founding member of the Society for Research on Nicotine and Tobacco (SRNT). He started the European affiliate in 1999 and served as president until 2003. In 2003, he was elected president of SRNT. His main research contributions have been in the fields of behaviour medicine, tobacco, and nicotine, with over 125 peer-reviewed publications (of which he is the primary author of 80). His current research interest is on reducing harm and exposure to tobacco toxins in those who cannot give up smoking. He has developed a scale for nicotine dependence (The Fagerström Test for Nicotine Dependence) and was awarded the WHO medal in 1999 for outstanding work in tobacco control.

Jerold Last, Ph.D. Jerold Last is Professor of Pulmonary/Critical Care Medicine at the University of California, Davis, School of Medicine and Director of the University of California, Davis, Fogarty International Center, in South America. From 1985 to 2004 he was Director of the University of California Systemwide Toxic Substances Research and Teaching Program. His research interests include animal models of asthma and lung fibrosis, inhalation toxicology, and environmental toxicology. Dr. Last has edited six books, and has served on the editorial boards of Toxicology and Applied Pharmacology and Experimental Lung Research, and is currently the associate editor of Toxicology and Applied Pharmacology. He has provided support and expertise to numerous governmental committees and agencies on issues relating to toxic substances in the environment. Dr. Last has published over 190 articles, including a review of toxic interactions between inorganic gases and particles and studies on the effects of exposure to sidestream and environmental tobacco smoke.

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Robert Orth, Ph.D. Robert Orth is a Physical Chemist at Apis Discoveries, L.L.C. He is also a Consultant to the Monsanto Company and an Adjunct Associate Professor of Physical Chemistry at the University of Missouri, where he teaches undergraduate courses in physical chemistry, instrumental analysis, and general chemistry. He has conducted research in secondary ion mass spectrometry and taught at the University of Utah and Montana State University. Dr. Orth held positions of increasing responsibility during a 16- year career with the Monsanto Company. His work focused on environmental chemistry and remediation, and in food and agricultural science. His current work at Apis Discoveries includes establishing business units for ultratrace analysis, consulting for companies submitting direct and indirect food additives to the U.S. Food and Drug Administration, and studying the analysis and remediation of organic pollutants. He has more than 100 publications and presentations in analytical and physical chemistry, and holds two patents.

Glenn Talaska, Ph.D., C.I.H. Glenn Talaska is Professor of Environmental Health in the Divisions of Industrial and Environmental Hygiene and Toxicology at the University of Cincinnati and a Certified Industrial Hygienist. Dr. Talaska received his Ph.D. in genetic toxicology from the University of Texas Medical Branch at Galveston in 1986 and conducted postdoctoral research at the National Center for Toxicological Research in Jefferson, AK from 1986 to 1989. Dr. Talaska has been on the faculty of the University of Cincinnati since 1989. His research is in the field of biological monitoring, with an emphasis on carcinogen biomarkers, involving metabolite and DNA adduct analysis and cytogenetics. His research includes human projects investigating the effects of tobacco smoking on levels of DNA adducts in placental tissue, the influence of various diets on DNA damage in exfoliated urothelial cells of smokers, genotoxic exposures in the rubber industry, and the effect of hair dye use on DNA adduct levels in exfoliated urothelial cells. Dr. Talaska also conducts research on DNA damage in human and animal breast tissues caused by polycyclic aromatic hydrocarbons (PAH) and the interaction between exposure to arsenic and PAH. His development and use of an exfoliated urothelial cell assay for DNA adduction and damage is one of the few cases where a representative sample of an important target organ for environmental carcinogens can be obtained by non-invasive means. Dr. Talaska is Vice-Chair of the Biological Exposures Indices Committee of the American Conference of Governmental Industrial Hygienists, a member of the American Academy of Industrial Hygiene, and Genetic Toxicology Consultant to the Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute.

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He is a member of the Editorial Board of the Journal of Environmental and Occupational Health and of the International Advisory Board of Yonsei Medical Journal, and is Associate Editor of Polycyclic Aromatic Compounds. Dr. Talaska has published 90 articles and 11 book chapters.

William Waddell, M.D. William Waddell is Emeritus Chairman of Department of Pharmacology and Toxicology at the University of Louisville. He served on the faculties of the University of North Carolina and University of Kentucky prior to his tenure at the University of Louisville, School of Medicine. He is a member of the editorial board of Human and Experimental Toxicology. Dr. Waddell has authored over 100 peer-reviewed articles, including studies on localization of nicotine and its metabolites in the mouse and reviews on thresholds on carcinogenicity. He has given more than 100 invited lectures around the world, has served as the chair of national scientific organizations and as a consultant to several drug and chemical companies.

VIII.A.2.2 Biological Effects Assessment Committee John A. Ambrose, M.D., F.A.C.C. John A. Ambrose is Professor of Medicine at New York Medical College, Valhalla, NY. He obtained his M.D. from New York Medical College and completed his internship and residency in internal medicine and a fellowship in cardiology at Mount Sinai Hospital, NY. Dr. Ambrose held positions with increasing responsibilities at Mount Sinai Medical Center and the New York Medical College, NY. He also served as Medical Director of the Comprehensive Cardiovascular Center and Chief of Cardiology at Saint Vincent Catholic Medical Centers, NY. Dr. Ambrose has published more than 100 articles in the field of cardiology, specializing in the mechanism of unstable angina and myocardial infarction. He is a member of several professional organizations and serves as President of the New York State Chapter of the American College of Cardiology and President of the New York Cardiologic Society. He also serves on the Annual Scientific Session Program Committee of the American College of Cardiology, and the Cardiac Advisory Board of the New York State Department of Health and on the editorial boards of Cardio Intervention and Revista Cardiologist. The New York Medical College Alumni Association awarded him the Gold Medal of Honor.

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Mark W. Frampton, M.D., F.A.C.P. Mark W. Frampton is Professor of Medicine and Environmental Medicine at the University of Rochester, NY. He obtained his M.D. from New York University and completed his internship and residency in internal medicine at Buffalo General Hospital, Buffalo, NY. Dr. Frampton completed his fellowship at the Pulmonary and Critical Care Unit, University of Rochester. He has worked as a visiting scientist at the Environmental Protection Agency and held a faculty position at the University of Rochester since 1988. He is Director of Pulmonary and Critical Care Research, Director of the Pulmonary and Critical Care Fellowship Program, and Director of the Pulmonary Function Laboratory at Strong Memorial Hospital. Dr. Frampton is also attending physician at Strong Memorial Hospital and Highland Hospital, both in New York. His research activities focus on the effects of particulate exposure on lung function, airway inflammation, and cardiovascular function, including the effect of ultrafine particle exposure on endothelial function. He is a member of the American Thoracic Society where he is past Chair of the Section on Terrorism and Inhalation Disasters. He is also a member and past President of the New York State Thoracic Society. Dr. Frampton serves on the editorial board of Inhalation Toxicology and Particle and Fibre Toxicology. He has served on various national advisory and health councils and research review committees and as a consultant to numerous health and science agencies.

James P. Kehrer, Ph.D. James P. Kehrer is the dean of the College of Pharmacy at Washington State University. Dr. Kehrer was formally the Gustavus and Louise Pfeiffer Professor of Toxicology and Director of the Center for Molecular and Cellular Toxicology at the University of Texas at Austin. He received his Ph.D. in pharmacology and toxicology from the University of Iowa College of Medicine and completed postdoctoral work in toxicology in the Biology Division of Oak Ridge National Laboratory. Since then he has held various positions with increasing responsibilities at the University of Texas at Austin. In addition, Dr. Kehrer is Adjunct Professor in the Carcinogenesis Department at the M. D. Anderson Cancer Center and a member of the U.S. EPA Science Advisory Board Environmental Health Committee. Dr. Kehrer’s research focuses on the mechanisms by which cyclooxygenase-2 inhibitors exert chemopreventive and anticancer activities. He is particularly interested in determining the basis for the selective toxicity to tumor cells, and also the roles of thioredoxin, glutathione, oxidized lipid species, and free radicals in signaling pathways related to apoptosis. Dr. Kehrer has authored more than 130 scientific publications and has published one book. He serves as editor for Toxicology Letters, deputy chairman of the editorial board for the

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Biochemical Journal, and is on the editorial boards for Toxicology and Applied Pharmacology and Archives of Biochemistry and Biophysics. Dr. Kehrer is a member of several professional organizations, including the Society of Toxicology, American Association of Cancer Research, American Association for the Advancement of Science, and American Society for Pharmacology and Experimental Therapeutics, where he is Chairman-elect of the Toxicology Division.

Loren D Koller, D.V.M., Ph.D., A.T.S. Loren D. Koller is President of Loren Koller & Associates, L.L.C., and specializes in environmental health and toxicology. He received his D.V.M. from Washington State University and a Ph.D. from the University of Wisconsin. Dr. Koller has over 30 years experience as a researcher in the areas of pathology, toxicology, immunology, carcinogenesis, and nutrition. He was previously employed as Head of Diagnostic and Comparative Pathology at the National Institute of Environmental Health Sciences and has held academic positions at the University of Idaho and Oregon State University, where he served as Professor and Dean of the College of Veterinary Medicine for 10 years. He has published in numerous peer- reviewed journals, served on several editorial boards and grant review panels and as a consultant to government, business, and private firms. Dr. Koller has been engaged in biomedical environmental research relating to health effects in humans most of his career. He has experience and knowledge in agriculture, biomedicine, and environmental health, with an appreciation and sensitivity of the issues involved in developing federal regulations. He has served on committees for the National Cancer Institute, National Academy of Sciences (National Research Council and Institute of Medicine), Agency for Toxic Substances and Disease Registry, Centers for Disease Control and Prevention, U.S. Army, Environmental Protection Agency, and on the National Advisory Committee to Establish Acute Exposure Guidelines for Hazardous Substances. Dr. Koller is also a member of the Association for Assessment and Accreditation of Laboratory Animal Care International Board of Trustees, chaired an international workshop on Environmental Issues in Veterinary Medical Education , and served on the Expert Panel on Health Effects of Polychlorinated Biphenyls for the Commonwealth of Massachusetts. He was President of the Society of Toxicology’s Immunotoxicology Specialty Section and founding President of that organization’s Veterinary Specialty Section. Dr. Koller is Fellow of the Academy of Toxicological Science.

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John F. Lechner, Ph.D. John F. Lechner is a Senior Research Scientist at the Ohio State University Comprehensive Cancer Center. He received his B.S. in agriculture from Cornell University, Ithaca, NY, and a Ph.D. in microbiology from Hahnemann University, Philadelphia, PA. Previous to his current position, Dr. Lechner served as Diagnostic Director for Oncology Programs with Bayer Diagnostics, Berkeley, CA, as Professor of Oncology/Pathology/Pharmaceutical Sciences at Wayne State University School of Medicine, and was Chief of the Aerodigestive Carcinogenesis Program at Karmanos Cancer Institute, both in Detroit, MI. His research interests include the molecular mechanisms of disease detection, carcinogenesis mechanisms, and the management of research. He has published one book and more than 140 articles. Dr. Lechner is reviewing editor for In Vitro Cellular and Developmental Biology and is an ad hoc reviewer for numerous cancer journals. He is a member of many professional associations, including the American Association of Cancer Research, American Society for Cell Biology, and American Association of Pathologists. He has also provided consultant services to public agencies, foundations, professional associations, and private enterprises.

Russell P. Tracy, Ph.D. Dr. Tracy obtained his Ph.D. in biochemistry from Syracuse University, NY and did post-doctoral work in clinical chemistry and protein biochemistry at the Mayo Clinic. He is a Board-certified Clinical Chemist, and has directed clinical chemistry laboratories at Strong Memorial Hospital in Rochester, NY and Fletcher Allen Health Care in Burlington, VT. He is currently Professor of Pathology and Biochemistry and Senior Associate Dean of Research and Academic Affairs at the University of Vermont, College of Medicine, Burlington. His research interests include the interrelationships of coagulation, fibrinolysis, and inflammation, especially the innate and adaptive immune systems. He explores their roles in the etiology of atherosclerosis and coronary heart disease, insulin resistance and diabetes, and more broadly in chronic diseases of aging, using both biomarkers and animal models. He has a long standing interest in CVD risk modeling and risk assessment. He also collaborates on studies of murine models of atherosclerosis. Current epidemiological studies include the Cardiovascular Health Study, the Health, Aging and Body Composition Study, and the Multi-Ethnic Study of Atherosclerosis; his laboratory also performs core lab work for clinical trials in the area of heart disease. His laboratory acts as a biological sample repository, currently housing over 100 -80°C freezers and close to 3 million samples of serum, plasma, cells, and DNA.

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VIII.A.2.3 Population Effects and Behavior Assessment Committee Warren Bickel, Ph.D. Warren Bickel is Director of the Arkansas Center on Addictive Behaviors, a joint program of the University of Arkansas for Medical Sciences (UAMS) Colleges of Medicine and Public Health. He is also Director of the Interdisciplinary Tobacco Program in the UAMS College of Public Health and is Wilbur D. Mills Chair of alcoholism and drug abuse prevention in the UAMS College of Medicine. Dr. Bickel obtained his Ph.D. from the University of Kansas in 1983. He was a postdoctoral fellow at The Johns Hopkins University School of Medicine before taking a faculty position at the Albert Einstein College of Medicine. Dr. Bickel served as Principal Investigator on four grants from the National Institute on Drug Abuse (NIDA) examining the behavioral processes that underlie drug dependence in humans and examining novel cost-effective ways to deliver treatment. Dr. Bickel was formerly Co-Director of the Human Behavioral Pharmacology Laboratory, the Substance Abuse Treatment Clinic, and the Training Program in Human Behavioral Pharmacology at the University of Vermont, where he also served as a professor in the departments of Psychiatry and Psychology and Vice- Chair for Research in the Department of Psychiatry. He is a recipient of the American Psychological Association’s Young Psychopharmacologist Award and of the College on Problems of Drug Dependence’s Joseph Cochin Young Investigator Award. In 1997, he received a MERIT award from NIDA. Dr. Bickel has published more than 150 research reports, reviews, and book chapters.

Harriet de Wit, Ph.D. Harriet de Wit has served on the faculty of the Department of Psychiatry at the University of Chicago for over 20 years, where she is currently Associate Professor and Director of the Human Behavioral Pharmacology Laboratory. She obtained her Ph.D. in experimental psychology from Concordia University in Montreal, Canada. She has several publications on the different cues involved in smoking and their interactions with other agents. Dr. de Wit studies the psychopharmacology of drugs of abuse. Her current research interests include genetic sources of individual variation in responses to drugs, interactions between acute stress and drugs, and the role of impulsivity in drug abuse. She is Deputy Editor for Alcoholism: Clinical and Experimental Research, as well as a field editor for the journal, Psychopharmacology. Dr. de Wit also serves on the Training and Career Development Subcommittee Initial Review Group of the National Institute on Drug Abuse. She is a Fellow of several scientific organizations, including the American College of Neuropsychopharmacology. In 1999, Dr. de Wit received the Solvay Award for Outstanding Basic Psychopharmacological Research in Affective Disorders from the American Psychological Association (Division 28).

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William Eadington, Ph.D. William Eadington is a Professor of Economics and Director of the Institute for the Study of Gambling and Commercial Gaming at the University of Nevada, Reno. He obtained his Ph.D. in economics from Claremont Graduate University, CA. Dr. Eadington is an internationally recognized authority on the legalization and regulation of commercial gambling, and has written extensively on issues relating to the economic and social impacts of commercial gaming. He has served as a consultant and advisor for government and private sector organizations throughout the world on issues related to gaming laws, casino operations, regulation, gambling legalization, and public policy. Dr. Eadington has served as a visiting professor to several academic institutions, including the Center for Addiction Studies at Harvard Medical School, and the Centre for the Study of Gambling and Commercial Gaming at the University of Salford, U.K. Working with universities in China, Macao, Canada, Slovenia, Australia, and the United States, he has played essential roles in developing courses and academic programs in gaming management and public policy and gambling. Dr. Eadington received the Outstanding Research/Education Award from the National Council on Problem Gambling in 1989, was awarded the University Foundation Professorship from the University of Nevada in 1990, and was awarded the Philip G. Satre Chair of Gaming Studies from the University of Nevada, Reno, in 2004. He serves on the Board of Directors of the National Council on Problem Gambling ,and on the Advisory Boards of the National Center for Responsible Gambling and South Africa’s National Responsible Gambling Programme.

Gregory P. Gasic, Ph.D. Gregory Gasic is the Associate Director for Neuroscience and Genetics at the Harvard Medical School Division on Additions; Director of the Laboratory of Neurogenetics in the Athinoula A. Martinos Center for Imaging, Department of Radiology, Massachusetts General Hospital; Co-Director of the Motivation Emotion Neuroscience Collaboration; and Instructor in the Department of Radiology, Harvard Medical School. He has worked on several research projects involving cell membrane physiology of red cells, organic chemistry of prostaglandin endoperoxides, thromboxanes, and prostacyclin, and their roles as local messengers in platelet and cardiovascular physiology. Dr. Gasic was part of the first group to synthesize prostacyclin and characterize it beneficial cardiovascular properties. He carried out postdoctoral work at Yale University, using physiological approaches to attempt to clone the NMDA receptor, and a second project to characterize the neuromuscular acetylcholine receptor in oocytes by electrophysiological and biochemical approaches. Subsequently, he carried out additional research at the Salk Institute, where the first glutamate receptor subunits had been cloned. Dr.

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Gasic has been the Neuroscience Editor of Nature, Deputy to the Editor of Cell, and Editor in Chief of Neuron, where he helped shape the course of neuroscience from the biophysics of ion channels to the systems involved in memory, perception, goal directed behavior, attention, and other higher cognitive functions. He is currently working on the application of morphometric MRI and functional MRI to understanding the brain regions that guide motivated behavior, and the changes in these regions that lead to susceptibilities to drug addictions and major depressive disorders.

Heping Zhang, Ph.D. Heping Zhang is a Professor of Biostatistics in the Department of Epidemiology and Public Health at Yale University. He obtained his Ph.D. in statistics from Stanford University. Dr. Zhang is Director of the Collaborative Center for Statistics in Science, which operates in collaboration with members from Yale University, the University of Alabama at Birmingham, the University of Pennsylvania, the University of Texas Medical Branch at Galveston, and the University of Utah. His group conducts research in the general area of regression and classification analyses and in the methodologies for post- genome data analyses. Dr. Zhang has made major research efforts into child health, ranging from the identification of neurological and genetic pathways in the developing brain to the assessment of risk factors for pregnancy outcomes and the understanding of cognitive and behavioral development in children and substance use, especially in understanding the transition from use to abuse. He serves as Editor for the Series in Biostatistics and as Associate Editor for Biometrics. Dr. Zhang was formerly the Deputy Head of the Academic Committee at the Center for Statistical Research, Chinese Academy of Sciences. He has received several awards and honors throughout his career, including an Independent Scientist Award from the NIH/National Institute on Drug Abuse in 2004, and a FIRST Award from the National Institute of Child Health and Human Development (1994- 2002). He was elected as a member of the International Statistical Institute in 1995, a Fellow of the American Statistical Association in 2000, and a Fellow of the Institute of Mathematical Statistics in 2006. His current research projects include methodological research on substance use; statistical methods in genetic studies of substance use; research training in mental health epidemiology; and data management, statistics, and informatics core.

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VIII.A.3 Life Sciences Research Office (LSRO) Staff Amy M. Brownawell, Ph.D. is a Staff Scientist at the Life Sciences Research Office in Bethesda, MD. She completed her postdoctoral training in the Center for Cell Signaling at the University of Virginia where she conducted research on the nuclear transport mechanisms of proteins and RNA. Dr. Brownawell obtained her Ph.D. in cellular and molecular pharmacology at the University of Virginia and holds both a B.S. and M.S. in chemistry from Georgetown University. She has co-authored thirteen peer-reviewed journal articles and two book chapters, served as editor for LSRO’s Dental Amalgam Review report, and is a member of the American Society for Cell Biology, Sigma Xi, and the Society of Toxicology.

Dr. Michael Falk, Ph.D. is the Director of the Life Sciences Research Office. He received his Ph.D. in biochemistry from Cornell University and completed postdoctoral training at Harvard Medical School. He was employed in various capacities at the Naval Medical Research Institute, Bethesda, MD, supervising as many as 80 senior level scientists. As Principal Investigator, he was a key member of the Scientific Advisory Board and the Acting Director for the Institute. He was also the Director of the Wound Repair Program and pioneered a new position as the Director of Biochemistry and Cell Biology. Also, as Director, he rescued the Septic Shock Research Program by cutting inefficiencies and increasing productivity in terms of grant funding and publication production. He managed peer review and subject review panels in infectious diseases, environmental sciences, military medicine, and other health-related fields. He was a peer reviewer for research proposals for NSF, Medical Research Council of Canada, and Office of Naval Research. As the Director LSRO, Dr. Falk evaluates biomedical information and scientific opinion for regulatory and policy makers in both the public and private sectors. Among his many accomplishments, he has produced seminal white papers on infant nutrition, food labeling, food safety, and military dental research and has organized two international conferences. Concurrently, he is with MCF Science Consultants, providing analysis and consultation on emerging technologies. Dr. Falk has published over 60 research articles, abstracts, technical reports, and presentations.

Robin S. Feldman, B.S., M.B.A. is the Literature Specialist at the Life Sciences Research Office. She is a seasoned information specialist with experience in the electronic acquisition, analysis, and management of scientific, business, and regulatory information. Ms. Feldman obtained her B.S. from the George Washington University in Washington, DC with a major in Zoology and her M.B.A. degree from the University of Maryland at College Park with a concentration in science and technology. Previously, she worked

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as a Biomedical Research Assistant at Consultants in Toxicology, Risk Assessment and Product Safety, where she obtained and researched scientific literature for private and government clients. At the National Alliance for the Mentally Ill, she designed and implemented a document management and retrieval system for the Biological Psychiatry Branch of the National Institute of Mental Health and served as Managing Editor of Bipolar Network News, a newsletter for the Stanley Foundation Bipolar Network. At Howard Hughes Medical Institute (HMMI), she oversaw the implementation of the HHMI Predoctoral Fellowship in Biological Sciences program. While serving as Science Information Specialist at the Distilled Spirits Council of the United States, she managed the installation of a local area network and participated in the development and maintenance of an electronic research database for the beverage alcohol industry. As a Report Coordinator at Microbiological Associates, Inc., she conducted statistical analyses and prepared technical reports about toxicology studies using animal models. She served as data management administrator for the National Toxicology Program’s sponsored studies. Currently, Ms. Feldman maintains LSRO’s library, responds to requests for reports, and assists LSRO’s scientists in discovering, obtaining, compiling, and documenting the scientific literature required to prepare reports for sponsors.

Karin French, B.S. is a former Associate Staff Scientist at the Life Sciences Research Office. Ms. French received one B.S. in animal science and another in cell and molecular biology and genetics from the University of Maryland at College Park (UMCP). In addition, she earned a College Park Scholars Certificate in “Science, Technology, and Society.” Ms. French worked in the Dairy Nutrition Laboratory at the university, helping Maryland dairy farmers use milk urea nitrogen (MUN) to evaluate herd protein nutrition. She helped design and complete studies to compare and evaluate the MUN analysis techniques used in the National Dairy Herd Improvement Association laboratories. Ms. French is currently pursuing doctoral studies at UMCP.

Kara D. Lewis, Ph.D. is a Staff Scientist at the Life Sciences Research Office. Dr. Lewis completed postdoctoral research at Yale University. She obtained her Ph.D. in biology with a concentration in neuroscience from Clark University and graduated summa cum laude with a B.S. in biology from Spelman College. Dr. Lewis has conducted research on taste and smell of the fruit fly, Drosophila melanogaster, and on the molecular mechanisms of sweet taste transduction in the blowfly, Phormia regina. She has collegiate teaching experience and three peer-reviewed publications. She is a member of the Association for Chemoreception Sciences.

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Rebecca Johnson, Ph.D. is the Assistant Information Specialist at the Life Sciences Research Office. Dr. Johnson received her B.A. from Wesleyan University, CT and her Ph.D. in anthropology with a concentration in archaeology from the University of Iowa. Her dissertation research examined dietary change between two Native American villages in southeastern Iowa, dated to 1950 and 100 B.P., by looking at fatty acid residues extracted from pottery. Dr. Johnson has performed fieldwork across the Mid-Atlantic and Upper Midwest, as well as in South Carolina, Great Britain, and Poland. Currently, Dr. Johnson assists in maintaining the LSRO library, responding to requests for reports, and organization of the scientific literature required by staff scientists for sponsored projects. Prior to joining LSRO, Dr. Johnson developed and maintained statewide archaeological databases for Iowa’s Office of the State Archaeologist.

Keith Lenghaus, Ph.D. is a former Staff Scientist in the Life Sciences Research Office. He has degrees in both chemical engineering and chemistry. Dr. Lenghaus completed his Ph.D. in chemical engineering in 2000 at the University of Melbourne. He subsequently obtained a postdoctoral research position in the Department of Bioengineering at Clemson University, where he conducted research into protein adsorption under microfluidic conditions. Dr. Lenghaus then spent a year as a guest researcher at the National Institute of Standards and Technology in Gaithersburg, MD before being appointed assistant professor at the University of Central Florida Nanoscience and Technology Centre. Dr. Lenghaus currently resides and works in Sydney, Australia.

Paula M. Nixon, Ph.D. is a former Staff Scientist at the Life Sciences Research Office. Dr. Nixon completed her postdoctoral research at The Babraham Institute in Cambridge. She obtained her Ph.D. in molecular biology from Imperial College London as part of Cancer Research UK. She graduated with an honors degree in molecular biology from the University of Manchester, UK. Dr. Nixon has conducted research on the MEK5/ERK5 MAP kinase pathway and the role of the AP-2 transcription factors in the control of gene expression in breast cancer. In addition, she was involved in research to identify the Currarino syndrome gene and the development of mitochondrial DNA profiling techniques for forensic science. She has three peer-reviewed publications and is a member of the American Society for Biochemistry and Molecular Biology and the European Medical Writers Association. Dr. Nixon currently resides and works in Cambridge, England.

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James Cecil Smith Jr., Ph.D. is a Senior Scientific Consultant at Life Sciences Research Office. Dr. Smith obtained his doctorate in nutritional sciences/biochemistry at the University of Maryland and completed postdoctorate work in the Department of Biological Chemistry, UCLA. He served two years as Health Service Officer at the National Institutes of Health. Dr Smith completed 36 years in federal research laboratories with increasing responsibilities in the Veterans Administration medical system and the U.S. Department of Agriculture (USDA). Although best known for contributions to trace element nutrition, he is also an authority in the area of vitamin and mineral interactions. Original research directed by him identified a link between zinc and vitamin A, which was published in Science. Other research accomplishments include collaborating on studies that revealed an important interaction between copper and dietary carbohydrates. He directed two large human investigations, funded in part by the National Cancer Institute, which established the USDA Laboratory and Research Center at Beltsville, MD as original leaders in research to elucidate the role of dietary carotenoids in health and disease. Dr Smith has authored or co-authored more than 375 publications. He served as an editorial board member, assistant editor, and ad hoc reviewer for several national/international journals. He is a member of several professional societies; his recognitions include the Klaus Schwarz Award for Excellence and Leadership in Trace Element Research sponsored by the International Association of Bioinorganic Scientists, and he was recently named a Fellow of the American Society for Nutritional Sciences.

Catherine L. St. Hilaire, Ph.D. is a Senior Staff Scientist with more than 20 years of experience in environmental and consumer product risk assessment and risk management. Dr. St. Hilaire has provided leadership in the development of risk assessment policies and procedures, from the original Risk Assessment Guidelines for Carcinogens and the original guidelines for EPA’s Superfund Risk Assessments, to industry-wide risk assessment approaches for food contaminants. Her contributions to the field have been formally recognized through her election as a Fellow of the Society for Risk Analysis and as a recipient of The National Academies’ “Certificate for Outstanding Service” on the 20th anniversary of the release of the landmark “Red Book.” This document formally known as Risk Assessment in the Federal Government: Managing the Process became a foundation of theory and practice in the field of risk assessment and provided the framework for public health risk assessments adopted by regulatory agencies worldwide. Dr. St. Hilaire has held executive-level posts at Hershey Foods Corp., International Life Science Institute, ENVIRON Corp., and Sciences International, Inc. She is the primary author of more than 20 books and publications in the fields of microbiology and toxicology, including

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carcinogenesis and reproductive and developmental toxicity, risk assessment, and risk management. She is a member of the Society for Risk Analysis and the Society of Toxicology.

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VIII.A.4 Life Sciences Research Office Board of Directors

Taffy J. Williams, Ph.D., Chair Consultant Concord, NC

Terry Quill, M.S., J.D., Vice Chair The Weinberg Group, Inc. Washington, DC

DIRECTORS Rita R. Colwell, Ph.D. University of Maryland College Park, MD

Eileen Kennedy, Ph.D. Tufts University Boston, MA

William MacLean, Jr., M.D., C.M., F.A.A.P. Consultant Columbus, OH

Thomas Stagnaro, B.S., M.B.A. Americas Biotech Distributor Riva, MD

Jacob J. Steinberg, Ph.D. Albert Einstein College of Medicine Montefiore Medical Center Bronx, NY

Michael Williams, Ph.D., D.Sc. Cephalon, Inc. West Chester, PA

Michael C. Falk, Ph.D., Secretary Life Sciences Research Office Bethesda, MD

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Abuse liability The potential for abuse and increased addiction.

Addiction A chronic, relapsing disease characterized by compulsive drug seeking and abuse and by long-lasting neurochemical and molecular changes in the brain. (National Institute on Drug Abuse, 2006).

Animal model of disease A test in animals developed to mimic human disease pathogenesis following exposure to toxins, which, in this case, is cigarette smoke.

Animal testing Animals are used for in vivo studies as surrogates for humans. Rodents are most frequently used for studies involving cigarette smoke.

Battery of tests A set of tests that have been chosen to provide a broad assessment of particular biological measures (e.g., cytotoxicity and genotoxicity test batteries, biomarker test batteries).

Behavioral studies The study of individual human or animal behavior. The term “behavioral” refers to overt actions; to underlying psychological processes such as cognition, emotion, temperament, and motivation; and to biobehavioral interactions (Office of Behavioral and Social Sciences Research, 2006).

Biological effects assessment One of two critical evaluations included in a PRRTP risk assessment. Statistically and biologically significant changes indicative of decreased risk in relevant biomarkers of effect in PRRTP users compared to those in conventional cigarette smokers support the likelihood that risk of lung cancer, chronic obstructive pulmonary disease and/or cardiovascular disease will be lower for PRRTP users.

Biological matrix A discrete material of biological origin (e.g., blood, serum, plasma, urine, or saliva), that can be sampled and processed in a reproducible manner (U.S. Food and Drug Administration, 2001).

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Biologically effective dose The amount of a constituent or metabolite that is measured interacting with critical subcellular, cellular, and target tissues.

Biomarker A biological response variable that is measured in biological fluids, tissues, cells, and subcellular components and is indicative of exposure and/or effect.

Biomarker of effect A measured effect including early subclinical biological effects; alterations in morphology, structure, or function; or clinical symptoms consistent with the development of health impairment and disease.

Biomarker of exposure A constituent or metabolite that is measured in a biological fluid or tissue or is measured after it has interacted with critical subcellular, cellular, or target tissues.

Cancer A term for diseases in which abnormal cells divide without control.

Cardiovascular disease Disease of the heart and/or vascular (blood vessel) system including atherosclerosis, coronary artery disease, carotid artery disease, and myocardial infarction (heart attack).

Cessation (smoking) Successful smoking cessation is defined as abstinence from smoking for at least six months (Centers for Disease Control and Prevention, 2005a).

Chippers Individuals who smoke several cigarettes per day, two to three times per week, but do not progress in amount or frequency and do not meet the criteria for nicotine dependence.

Chronic disease In humans, a disease that develops over a period of years to decades. In animals (rodents), a disease that develops over a number of months to 1-2 years.

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Chronic obstructive pulmonary disease (COPD) A slowly progressive disease of the airways that is characterized by a gradual loss of lung function. In the US, the term COPD includes chronic bronchitis, chronic obstructive bronchitis, or emphysema or combinations of these conditions.

Cigarette A rod of tobacco wrapped in paper.

Cigarette smoke condensate The particulate phase of cigarette smoke. Includes liquid and/or solid particles within the smoke aerosol.

Cigarette smoking machine A machine that generates smoke from a cigarette according to one or more defined protocols.

Cigarette smoking machine regimens A set of conditions for the production of smoke from cigarettes using a smoking machine. In general, regimes differ in puffing (e.g., volume, duration, and inter-puff interval) and filter vent-blocking conditions.

Clinical studies Studies conducted with human subjects.

Comparative risk assessment A risk assessment where the risk associated with one set of exposures (e.g., from PRRTP) are compared to risk associated with a different set of exposures (e.g., from conventional cigarettes).

Continuing smokers Individuals who cannot or will not stop smoking.

Controlled smoking An intentional reduction in the number of cigarettes smoked per day in dependent smokers.

Conventional cigarettes Commercial cigarettes that incorporate materials and designs typical of those that have been used in cigarette manufacturing for a number of years (Counts et al., 2006).

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Cotinine A metabolite of nicotine found in the plasma, saliva, and urine of smokers and used as a biomarker of exposure to cigarette smoke.

Crossover studies A study in which each participant is used as his/her own control, removing inter-subject variations in responses.

Cytotoxicity tests Tests that measure the ability of a chemical or chemical mixture to damage or kill cells.

Dose The amount of substance absorbed by an organism.

Dose-response A relationship between the amount of a substance in environmental media that comes in contact with an organism (humans, animals) and/or the amount of a substance absorbed by an organism or a specified compartment, organ, or tissue, and the biological effects caused by the substance.

Early initiators Individuals who have tried up to 50 cigarettes over a relatively short time period, are experimenting with tobacco use, and may become regular smokers.

Emphysema A lung disease in which tissue deterioration results in increased air retention and reduced exchange of gases. The result is difficulty breathing and shortness of breath (National Institute on Drug Abuse, 2006).

Endpoint Measure of outcome (e.g., malignant tumor; myocardial infarction; death).

Environmental tobacco smoke Smoke consisting of aged, diluted sidestream smoke, and exhaled mainstream smoke.

Epidemiological studies Epidemiological studies are conducted using human populations to evaluate whether there is a causal relationship between exposure to a substance and adverse health effects. Epidemiological studies measure the risk of illness or death in an exposed population compared to that risk in an identical (e.g., same age, sex, race, social status) unexposed population.

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Epigenetic Modulation of regional chromatin organization, without alteration of DNA gene sequence, which influences gene expression (e.g., DNA methylation).

Exposure (external) The amount of a substance in environmental media that comes in contact with an organism (humans, animals).

Exposure (internal) The amount of a substance that is absorbed by an organism or specified compartment, organ, or tissue. Also referred to as dose.

Exposure assessment One of two critical components of a risk assessment. The purpose of an exposure assessment is to evaluate all relevant data on the exposure of interest (in this case chemicals present in PRRTP and conventional cigarette smoke).

Ex-smokers Individuals who do not currently use tobacco products, and have managed to successfully abstain from smoking for ≥ 6 months.

Failed initiators Individuals who have tried between 50 to 100 cigarettes (or equivalents) in their lifetime, over an extended period of time, have not progressed to a regular smoking habit, and are unlikely to become regular tobacco smokers.

Filter (cigarette) A device positioned at the mouth end of a cigarette, which serves as a smoke permeable mouthpiece, usually composed of cellulose acetate fibers in the US and encased by a wrapper.

Filter vents One or more rings of small holes or perforations intended to dilute smoke with air thereby reducing standard yields of tar, nicotine and carbon monoxide.

FTC method A cigarette smoking machine method first adopted by the Federal Trade Commission in 1967 to measure yields of tar, nicotine in mainstream smoke. The method was modified in 1980 to include carbon monoxide.

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Gas phase The nonliquid (vapor) phase of cigarette smoke, which is not readily condensable when passes through a filter, as compared to the particulate phase.

Gateway effect A term used in drug addiction/abuse literature that refers to the progression from a less addictive/less risky product to a more addicitive, riskier product. In the field of tobacco control, this term refers to the possibility that use of one tobacco product (e.g., a PRRTP) can lead to subsequent use of tobacco products that are more addictive and/or more harmful (conventional cigarettes).

Genotoxicity tests Tests of the propensity of a substance (in this case, cigarette smoke or a fraction of cigarette smoke) to damage the genetic material (DNA) of test cells; a more general term that encompasses mutagenicity tests.

Harm An adverse event (e.g., a tobacco-associated disease or health condition).

Harm reduction A reduction in adverse consequences associated with an activity or exposure to toxic substances, In general, harm reduction operates in an environment where harm is occurring and cannot be prevented or eliminated.

Health-related claim A statement that provides information that a product is associated with improved health outcomes. Such claims can be express or implied. For PRRTP, a statement that the risk of developing one or more diseases associated with smoking conventional cigarettes is, or may be, reduced is a health-related claim.

Initiation (smoking) Beginning to smoke for the first time.

Intended User In the case of PRRTP, continuing smokers who cannot or will not quit smoking.

In vitro test A test that is performed on single-cell organisms, such as bacteria or yeast, or single cells or organs derived from animals or humans.

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In vivo test A test that is performed in a whole, living animal or human.

Lung cancer Cancer that forms in tissues of the lung, usually in the cells lining the air passages. There are four main histological types, squamous cell, adenocarcinoma, small cell and large cell carcinoma.

Mainstream smoke Smoke drawn from the butt end of a cigarette into the mouth as a smoker puffs on a cigarette.

Morbidity A disease state; prevalence and/or incidence of disease.

Mortality Death.

Neuroimaging Neuroimaging refers to diverse techniques including computerized tomography (CT) scanning and magnetic resonance imaging (MRI) used to visualize the structural or functional patterns of the nervous system.

Never-smokers Individuals who have never smoked a cigarette.

Nicotine A cyclic tertiary amine composed of a pyridine and a pyrrolidine ring. It is a colorless to pale yellow, water soluble, fluid alkaloid derived from plants of the genus Nicotiana . Nicotine acts as a stimulant in mammals and is one of the main factors responsible for dependance-forming properties of tobacco smoke.

Nicotine dependence Is characterized by both tolerance and withdrawal symptoms in relation to nicotine use.

Nicotine Replacement Therapy Is the use of various forms of nicotine delivery methods intended to replace nicotine obtained from smoking or other tobacco usage. Examples include: nicotine patches, gums, inhalers, nasal sprays, and lozenges.

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Occasional smokers Individuals who are situational smokers, smoke less frequently than chippers and are not nicotine dependent.

Pack-year A pack-year is unit of measure of smoking exposure. One pack-year represents the consumption of 20 cigarettes per day (one pack) for one year by one person.

Particulate phase In smoke, the solid and/or liquid phase of an aerosol, that is suspended in gas. Liquid particles are referred to as droplets.

Pharmacokinetics The pattern of absorption, distribution and excretion of a drug over time.

Population risk The probability of harm within an aggregate or overall population.

Postmarketing evaluation Studies conducted after a PRRTP has been marketed including clinical studies of exposure and biological effects, behavioral studies, surveillance and epidemiological studies.

Postmarketing surveillance Surveillance is the ongoing systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event. Surveillance can be active or passive.

Potential reduced-exposure products (PREPs) Products that could potentially result in reduced exposure to toxicants from a given instance of tobacco use.

Potential reduced-risk tobacco products (PRRTP) Tobacco products that may pose lower health risks than conventional cigarettes.

Power of a test The probability of detecting a difference in the characteristics of two populations.

Preference testing Assesses the degree to which one option is preferred over another.

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Premarketing evaluation Testing that is conducted prior to the marketing of a product.

Product characteristics Composition, design and engineering of a tobacco product.

Preclinical studies Studies generally conducted prior to studies in humans. For PRRTP, preclinical studies include product characterization, chemistry (smoke or product), cytogenicity and genotoxicity, and animal studies.

Prospective studies Studies designed to assess outcomes in human subjects, such as the development of a disease, during the study period.

Pyrolysis Thermal degradation of a chemical substance, generally resulting in smaller chemical fragments.

Pyrosynthesis Formation of additional compounds by the recombination of fragments arising from incomplete combustion of a parent chemical/compound during pyrolysis.

Randomized controlled trial A clinical study in which investigators randomly assign eligible participants into control and test groups.

Reduced-yield cigarette A cigarette designed to reduce particulate matter (tar) in smoke generated using standard FTC smoking machine conditions.

Reference cigarette Cigarettes prepared under controlled conditions with uniform, documented source tobaccos producing standardized yields of ‘tar’, nicotine, and carbon monoxide.

Relative risk Expression of a risk in relation to another risk (e.g., the risk of death at work is approximately twice the risk of death from drowning).

Relapse Relapse occurs when an ex-smoker resumes his/her former habit of smoking cigarettes.

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Risk Probability that harm (e.g., a smoking-related disease) will occur.

Risk assessment A human health risk assessment is a systematic review and evaluation of data relating to the risks posed by occupational or environmental chemicals, consumer products, food components and drugs, and other potential health hazards (National Research Council, 1983).

Risk assessment policy Assumptions made in the face of scientific uncertainty that are judged to be protective of human health.

Risk characterization The final step in the risk assessment process where overall conclusions based on the weight of the evidence available are developed. It includes an analysis of the impact of scientific uncertainties on the conclusions reached and a statement of the overall confidence in the conclusions.

Risk management A process that occurs after a risk assessment has been completed that weighs decision options and selects the most appropriate one by integrating the results of risk assessment with other relevant factors, such as social, legal, economic and political concerns.

Risk perception How people perceive, or feel about, potential threats (i.e., risks).

Risk reduction A decrease in the likelihood that harm will occur.

Scientific judgment An informed opinion or assumption (also called an inference judgment) made when scientific uncertainty is confronted in a risk assessment.

Side stream smoke The smoke emitted directly into the air from the burning end of the cigarette, largely during the smolder interval between puffs.

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Smoke Usually a suspension of fine particles in air that scatters light and is physically visible. Cigarette smoke contains many chemical substances in both gas and liquid state, suspended in a dynamic aerosol created by incomplete combustion which changes both physically and chemically over time.

Smoker A person who smoked ≥ 100 cigarettes and who now smokes every day or some days (Centers for Disease Control and Prevention & National Center for Health Statistics, 2006).

Smoke chemistry studies Studies that investigate the general composition of smoke or the yield of specific smoke constituents.

Smokeless tobacco products Products that do not require combustion or production of tobacco aerosol (“smoke”) by other means at the time of use (World Health Organization Scientific Advisory Committee on Tobacco Products Regulation, 2003).

Smoking topography A method to study how individuals smoke cigarettes or cigarette-like products.

Smoking-related diseases Diseases that have been reported to be caused by cigarette smoking, such as those listed in the 2004 Surgeon General’s report (U.S. Department of Health and Human Services, 2004b).

Snuff A fine-ground smokeless tobacco product that is intended to be sniffed up the nose (dry snuff) or placed in the mouth between the lip and gum (moist snuff).

Snus A moist to semi-moist, ground, oral tobacco product which is placed between the upper lip and gum.

Standard methods Testing methods that have undergone appropriate validation (intra- and inter- laboratory evaluation) that are used to comparing results.

Stopping rules Criteria for early study termination.

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Structure-activity relationships Relationships linking chemical structure and toxicological effects.

Surrogate chemical A chemical that is used to represent other chemicals, that is similar in structure/chemical class.

Tar The weight in grams of the total particulate matter collected on a Cambridge filter minus the weight of alkaloids, as nicotine, and water (Federal Trade Commission, 1967a).

Tobacco harm reduction Reduction of adverse impacts on the health of those smokers who will not or can not abstain.

Tobacco-specific nitrosamines N-nitroso compounds formed by the nitrosation of the major tobacco alkaloid, nicotine and a suspected human carcinogen.

Total particulate matter Particles in smoke, larger than 1 μm in diameter, that are trapped on a Cambridge filter as the smoke passes through the filter; usually obtained from mainstream smoke.

Toxicant A poisonous substance.

Unintended user In the case of PRRTP, individuals who would otherwise be tobacco free.

Validated methods A test method that has undergone appropriate testing and has been shown to be adequate for its intended purpose (International Conference on Harmonisation Steering Committee, 1994).

Vapor phase Material in the gas state, usually material that passes through a filter.

Weight of evidence A process that assigns different levels of importance (“weights”) to evidence based on a number of factors. The term also refers to conclusions based on the totality of the evidence from all study types.

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Withdrawal A variety of symptoms that occur after chronic use of an addictive drug is reduced or stopped (National Institute on Drug Abuse, 2006).

Yield The amount of a substance, such as tar, nicotine, or carbon monoxide as produced in smoke under standard smoking conditions.

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VIII.B.2 ACRONYMS AAMA N-Acetyl-S-(2-carbamoylethyl)-L-cysteine BALF Bronchoalveolar lavage fluid BEA Biological Effects Assessment CC Core Committee CDC Centers for Disease Control and Prevention

CO2 Carbon dioxide CO Carbon monoxide COHb Carboxyhemoglobin COPD Chronic obstructive pulmonary disease CORESTA Centre de Coopération pour les Recherches Scientifiques Relatives au Tabac CT Computed tomography CVD Cardiovascular disease DHBMA or MI Dihydroxybutenyl-mercapturic acids DNA Deoxyribonucleic acid EA Exposure Assessment EBC Exhaled breath condensate EKG Electrocardiogram EPA U.S. Environmental Protection Agency ETS Environmental tobacco smoke FDA U.S. Food and Drug Administration FTC U.S. Federal Trade Commission GAMA N-(R,S)-acetyl-S-(2-carbamoyl-2-hydroxyethyl)-L- cysteine

H2O2 Hydrogen peroxide Hb Hemoglobin HDL High-density lipoprotein ICH International Conference on Harmonisation IOM Institute of Medicine LC Lung cancer LDL Low-density lipoprotein LSRO Life Sciences Research Office MHBMA or MII Monohydroxy-butenyl-mercapturic acids MRI Magnetic resonance imaging MS Mainstream smoke NCI National Cancer Institute NDMA Nitrosodimethylamine NIH National Institutes of Health NNAL 4-(methylnitrosoamino)-1-(3-pyridyl)-1-butanol NNK 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanone NO Nitric oxide

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NRC National Research Council NRT Nicotine replacement therapy OECD Organisation for Economic Co-operation and Development PAH Polycyclic aromatic hydrocarbons PEBA Population Effects and BehaviorAssessment PET positron emission tomography PME Postmarketing evaluation PREP Potential reduced-exposure product PRRTP Potential reduced-risk tobacco product RBC Red blood cell RRRP Reduced Risk Review Project SS Sidestream smoke SSRC State-of-the-Science Review Committee ST Smokeless tobacco 99mTc-DTPA 99mTechnetium-labeled diethylenetriamine penta- acetic acid THR Tobacco harm reduction TPM Total particulate matter TSNA Tobacco specific nitrosamines USDA U.S. Department of Agriculture vWF von Willebrand factor WBC White blood cell WHO World Health Organization

The distribution or electronic posting of this PDF file is strictly prohibited without the written permission of the Life Sciences Research Office. 172 Evaluation of Potential Reduced-Risk Tobacco Products INDEX A Chronic obstructive pulmonary Abuse liability, 86, 157 disease (COPD), 3, 7, 20-21, 40, 43, 57, 60, 64, 69-70, 77, 89, 159 Addiction, 86, 157 Cigarette, 159 Animal model of disease, 40-44, 68, conventional, 1-4, 6-7, 18-20, 24, 70, 73, 157 26-27, 30-31, 37, 46, 48, 53, Animal testing (studies), 4, 7, 26, 37- 57, 63, 65, 69-71, 77, 82-86, 39, 49, 72-73, 157, 165 88, 92, 157, 159, 161-162, 164 reduced-yield, 13-14, 29, 86, 165 B reference, 4, 20, 37, 165 Biological effects assessment, 46, smoking machines, 28-31, 159 69, 72-73, 75-77, 157 Commitees Biological matrix, 49-50, 52-53, 157 Core, 18 Biologically effective dose, 47, 158 State-of-the-Science, 19 Biological Effects Assessment, Biomarker, 4, 7, 46-64, 71-77, 158 19 cardiovascular, 61-63 Exposure Assessment, 19 chronic obstructive pulmonary Population Effects and disease, 60, 62 Behavioral Assessment, 19 lung cancer, 58-59, of effect, 4, 9, 46-47, 57-58, 63- Cotinine, 38, 40, 50-52, 160 64, 68, 72-73, 75, 77-78, 157- D 158 of exposure, 4, 9, 13, 19, 40, 46- Dose, 37-41, 47, 158, 160 56, 71-72, 75, 78, 158 Dose-response, 37, 39, 41, 43, 73, 76, 160 C Cancer, 3, 20-21, 24, 35, 41, 57-59, E 69, 75, 93, 158 Exposure lung, 3, 7, 13-14, 20-21, 24, 40, assessment, 71, 161 43, 57-59, 69-70, 77, 89, 92- external, 47, 161 93, 163 internal, 40, 47, 161 Cardiovascular disease, 3, 20-21, 24, 40, 43, 57, 61-64, 69-70, 77, F 89, 158 Filter Cessation (smoking), 1, 2, 10-13, 19, analysis, 49, 56 21-22, 48, 58, 80-83, 94, 158 cigarette, 13, 15, 27, 29, 161 assessment, 86-87 vent, 29-30, 159, 161 FTC method, 20, 29, 31, 37, 44, 161

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G Premarketing Gas phase, 40, 162 evaluation, 6-7, 165 Gateway effect, 88, 93, 162 Product characteristics, 26-27, 53, 80, 165 H Pyrolysis, 27-28, 165 Harm, 162 Pyrosynthesis, 27-28, 165 reduction, 13, 18, 80, 92-94, 162 tobacco harm reduction, 2, 12- R 13, 80, 88, 91-94, 168 Relapse, 19, 80-83, 165 Risk I assessment, 4, 16-18, 67, 69, Initiation (smoking), 19, 81-85, 88, 166 162 characterization, 69, 73-77, 166 Intended user, 6, 80-81, 84, 89, 162 comparative, 67-78, 159 individual, 3-5, 16 M management, 4, 16, 74, 78, 166 Morbidity, 6, 20, 80-81, 88, 163 perception, 86-87, 166 population, 6, 18, 80-89, 164 Mortality, 6, 20, 80-81, 88, 163 reduction, 2-4, 9, 16, 18, 69, 73, N 92, 166 relative, 93, 95, 165 Nicotine, 1, 12, 20, 28, 30-33, 48- 49, 51, 82-83, 92, 163 S dependence, 39, 68, 70-71, 163 Smoke, 148 nicotine replacement therapy environmental tobacco, 1, 10, (NRT), 1-2, 13, 16, 49, 51, 92, 33, 85, 160 163 mainstream, 28-33, 160, 163 P sidestream, 33, 85, 160, 166 Pack-year, 58, 164 Smoker, 1, 10-12, 48, 82-84, 92, 167 chippers, 84, 158 Particulate phase, 31, 33, 39-40, 44, continuing, 12, 14, 18, 69-70, 74, 71, 159, 162, 164 159 Postmarketing early initiator, 83-84, 160 evaluation, 6, 80-81, 88, 164 ex-smoker, 84, 161 surveillance, 88, 164 failed initiator, 84, 161 Potential reduced-exposure products never-smoker, 93, 163 (PREPs), 2, 16, 164 occasional, 84, 164 Potential reduced-risk tobacco- Smokeless tobacco products, 92-94, related products (PRRTP), 1, 5, 7, 167 9, 14-16, 26-27, 46, 64, 68-70, 80- snuff, 92, 167 81, 164 snus, 15, 92-94, 167

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Smoking topography, 30-31, 49, 53, Tobacco-specific nitrosamines 71, 167 (TSNAs), 15, 32, 52, 55-56, 168 Smoking-related diseases, 10, 16, Total particulate matter, 20, 28, 36, 18, 89, 167 39, 168 Structure-activity relationships Toxicant, 27, 44, 53, 71, 77, 164, 168 (SAR), 32, 168 Studies U behavioral, 2, 5-7, 80-83, 87-89, Unintended user, 6, 80-82, 89, 168 157 clinical, 46-65, 159 V epidemiological, 88-89, 160 Vapor phase, 33, 37, 53, 72, 162, preclinical, 3-5, 7, 16, 20, 24-44, 168 48, 72-73, 76, 165 prospective, 18, 63, 70, 165 W randomized controlled trial, 70, Weight of evidence, 3, 19, 68-69, 71- 88, 165 74, 168 Surrogate chemical, 31, 44, 52, 168 Withdrawal, 83-84, 87, 163, 169

T Y Tar, 13-14, 20, 24, 28-29, 32, 48, Yield, 20, 28-30, 32, 165, 167, 169 161, 165, 168 Tests animal, 37-43, 157 battery of, 34, 44, 56, 63, 157 cytotoxicity, 4, 7, 26, 31, 34-37, 44, 69-70, 72-73, 75-76, 157, 160 genotoxicity, 4, 7, 26, 31, 34-37, 44, 69-70, 72-73, 75-76, 157, 162 in vitro, 34-36, 162 in vivo, 34, 36, 157, 163 preference, 85-87, 164 smoke chemistry, 4, 7, 19, 28, 33, 51, 70-71, 167

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