Alternate Nicotine Delivery Systems and Airway Epithelial Biology

Hypothesis and Research Questions We hypothesize that shisha smoking and electronic
cigarettes both disorder airway biology, but this disordered biology differs from that
resulting from cigarette smoking, suggesting that these alternative nicotine delivery methods
will cause lung disease, but perhaps with phenotypes different from that of cigarette
smoking.

Aim 1: To assess the hypothesis that shisha smoking disorders the biology of the airway
epithelium, but that these changes are distinct from that of cigarette smokers.

Aim 2: To evaluate the hypothesis that when the smoker switches from smoking cigarettes to
smoking electronic cigarettes, there is a partial normalization of the disordered airway
epithelial biology, but that this partial normalization is different from that associated
from complete cessation of cigarette smoking.

Standard and Experimental Procedures

All of the study populations and assessments to be carried out in this protocol are already
covered under the IRB approved protocol, "Collection of Airway, Blood and/or Urine Specimens
from Subjects for Research Studies" (IRB #1204012331); the only purpose of this protocol is
to formalize the timing of assessments so that the underlying hypothesis can be assessed.

The above protocol is designed to assess gene expression in lung cells of nonsmokers, smokers
and ex-smokers. The purpose of the present study is to asses if shisha smoking and electronic
cigarettes both disorder airway biology, and see if this disordered biology differs from that
resulting from cigarette smoking, suggesting that these alternative nicotine delivery methods
will cause lung disease, but perhaps with phenotypes different from that of cigarette
smoking.

This new protocol will use our existing IRB approved protocol, "Collection of Airway, Blood
and/or Urine Specimens from Subjects for Research Studies ("Airway")" (IRB #1204012331), for
all of the assessments and procedures of this study. This protocol is designed to formalize
the time points at which we carry out the various test parameters (see Table II for a
timeline of the study parameters). Recruitment for this protocol will be from the cohort of
individuals who are recruited for the "Airway" study. Research subjects recruited into this
protocol, will sign both the "Airway" informed consent form and also the consent form for
this protocol.

The standard clinical care of our pulmonary physicians is to encourage all smokers to stop
smoking; hence, all research participants who smoke will be encouraged to stop smoking. If
they decide to do so, they will receive standard of care smoking cessation aids including
counseling and medications.

Subjects enrolled in Group E of the study will receive an alternative nicotine delivery
method such as electronic cigarettes.

Inclusion Criteria:

Group A - Nonsmokers

- All study subjects should be healthy according to the Weill Cornell IRB protocol
#1204012331 and be willing and able to provide informed consent for the follow up
study with repeated bronchoscopies.

- Subjects will be male and female ≥18 yr of age.

- Nonsmoker is defined as someone who has smoked <100 cigarettes or <10 shisha pipes per
lifetime and whose urine nicotine <2 ng/ml and/or urine cotinine <5 ng/ml, at entry
into the study.

Group B - Current cigarette smokers

- All study subjects should be healthy according to the Weill Cornell IRB protocol
#1204012331 and willing and able to provide informed consent for the follow up study
with repeated bronchoscopies.

- Subjects will be male and female ≥18 years of age.

- Active smoker is defined by self-report and urine nicotine >30 ng/ml and/or urine
cotinine >50 ng/ml.

Group C - Current shisha smokers

- All study subjects should be healthy according to the Weill Cornell IRB protocol
#1204012331 and willing and able to provide informed consent for the follow up study
with repeated bronchoscopies.

- Subjects will be male and female ≥18 yr of age.

- Shisha smoker is defined by self-report of smoking >4 pipes/wk and carboxyhemoglobin
>2.5.

Group D - Current smokers who stop smoking

- All study subjects should be healthy according to the Weill Cornell IRB protocol
#1204012331 and willing and able to provide informed consent for the follow up study
with repeated bronchoscopies.

- Subjects will be male and female ≥18 years of age.

- Current smoker is defined by self-report and urine nicotine >30 ng/ml and/or urine
cotinine >50 ng/ml.

- Subjects must be a current smoker willing to stop smoking with no contra indications
to taking varenicline.

Group E - Current smokers who switch to electronic cigarettes

- All study subjects should be healthy according to the Weill Cornell IRB protocol
#1204012331 and willing and able to provide informed consent for the follow up study
with repeated bronchoscopies.

- Subjects will be male and female ≥18 years of age. Current smoker is defined by
self-report and urine nicotine >30 ng/mL and/or urine cotinine >50 ng/ml.

- Subjects must be willing to switch from tobacco cigarettes to electronic cigarettes.

Exclusion Criteria:

All exclusion criteria apply from the "Airway" (IRB#1204012331) protocol. Additional
exclusion criteria specific to this protocol are as follows:

Groups A-E

- No Weill Cornell (including GMS) students will be included, but students from other
institutions may be included. A potential pool of Weill Cornell employees may enter this
study provided that they are not under the oversight of the study PI or co-investigators.

Groups D and E - Current smokers who stop smoking

- Subjects who are not, in the opinion of the responsible investigator, eligible to take
smoking cessation medication due to major depressive and/or other significant psychiatric
disorder.