This clinical trial evaluates how the content of waterpipe (WP) tobacco affects the appeal, puffing behavior, and toxicity of WP tobacco smoking. The data from the proposed study will provide direct links between WP tobacco's primary additives (sugars and humectants), CO and nicotine biomarkers, smoker preferences, perceptions of harm and puffing behaviors, and the subsequent range of toxicant exposures associated with these additives and behaviors. Study outcomes include waterpipe puffing behaviors, exhaled carbon monoxide levels, nicotine uptake, spirometry, sensory perceptions, smoking appeal, and risk perception. Waterpipe tobacco smoking is often the first combustible tobacco product tried by adolescents and young adults, possibly due to the widespread availability of heavily sweetened waterpipe tobacco and the perception that waterpipe smoking is a safer alternative to cigarette smoking. However, waterpipe tobacco smoking is associated with lung disease, carbon monoxide poisoning, and precursor conditions for oral and other cancers in adolescents and young adults. There is currently little data available on how the primary additives (by weight) in waterpipe tobacco affect puffing behaviors, toxicant exposures, pulmonary function and appeal. This clinical trial uses established waterpipe tobacco smokers, four investigational tobacco products with precisely manipulated levels of humectants and natural sugars in a single-blind, crossover (repeated measures) study design to determine how waterpipe tobacco additives effect human puffing behavior, nicotine uptake, flavor perceptions, lung function, and biomarkers of exposure.
Currently there are no regulations governing the content of WP tobacco. Because mandated changes in tobacco content may lead to unintended consequences that ultimately result in public health declines, human use behaviors must be well understood prior to implementing regulatory product standards. The proposed study will include preparing and characterizing the content of 4 investigational tobacco products (ITPs) (Aim 1); characterizing the mainstream smoke toxicant emissions from machine smoking the 4 ITPs using a single, established puffing regimen (Aim 2); measuring human puffing behavior, general harm and specific health risk and flavor perceptions, lung function, and biomarkers of exposure in a group of established WP smokers smoking the 4 ITPs in the laboratory (Aim 3), and estimating toxicant exposure ranges using machine smoking and puffing regimens derived from the human laboratory testing (Aim 4). The clinical trial (Aim 3) will focus on using a group of established adult and young adult WP smokers, a cross-over study design, CO and nicotine biomarkers, spirometry, cutting edge psychophysical measurement tools, and risk perception instruments to map the relationship between sensory experiences and preferences of sweetness and flavor to specific additive content in WP tobacco that affect these experiences, preferences, acute health effects, and toxicant exposures. Study subjects will participate in a series of 4 clinic sessions, each visit separated by at least a week, in which they smoke one of 4 tobacco preparations (single-blind) using a research grade waterpipe in a randomly assigned sequence in a smoking room with sufficiently controlled ventilation rate to keep ambient air CO levels below 25 ppm. Exhaled CO, whole blood samples and spirometry measures will be collected before and immediately after the smoking session. Taste perceptions, liking/disliking, and risk perceptions will be determined via questionnaires before, during, and after smoking.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
SINGLE
Enrollment
54
Ancillary studies
Smoke waterpipe tobacco
Ohio State University Comprehensive Cancer Center
Columbus, Ohio, United States
Change in Exhaled Breath Carbon Monoxide (CO)
Change from baseline exhaled breath carbon monoxide (boost). CO was collected before and immediately after each smoking session with a handheld electrochemical cell.
Time frame: Approximately 30 to 90 minutes
Change in Plasma Nicotine
Change from baseline plasma nicotine (boost): Whole blood was collected before and immediately after each smoking session, separated, and plasma layer transferred and stored at -80 °C until analysis for nicotine according to validated methods using LC-MS/MS.
Time frame: Approximately 30 to 90 minutes
Change in Forced Vital Capacity (FVC)
Spirometer measurements will be collected - change in forced vital capacity (FVC) (post-pre).
Time frame: Approximately 30 to 90 minutes
Change in Forced Expiratory Volume in 1 Second (FEV1)
Spirometer measurements will be collected - change in forced expiratory volume in 1 second (FEV1) (post-pre)
Time frame: Approximately 30 to 90 minutes
Change in FEV1/FVC; The Ratio of the Forced Expiratory Volume in the First One Second to the Forced Vital Capacity of the Lungs.
Spirometer measurements will be collected - change in FEV1/FVC, the ratio of the forced expiratory volume in the first one second to the forced vital capacity of the lungs (post-pre).
Time frame: Approximately 30 to 90 minutes
Change in Peak Expiratory Flow (PEF)
Spirometer measurements will be collected - change in peak expiratory flow (PEF) (post-pre).
Time frame: Approximately 30 to 90 minutes
Change in Forced Expiratory Flow at 25-75% of FVC
Spirometer measurements will be collected - change in forced expiratory flow at 25-75% of FVC (post-pre).
Time frame: Approximately 30 to 90 minutes
Tobacco Use History
Ever use of tobacco products, assessed at the first study visit
Time frame: Baseline
Nicotine Dependence (HONC)
Hooked on Nicotine Checklist (HONC) comprised of 10 "Yes" or "No" questions, assessed on the first study visit. Scores range from 0 to 10 with higher scores indicating greater nicotine dependence.
Time frame: Baseline
Nicotine Dependence (LWDS)
Lebanese Waterpipe Dependence Scale (LWDS) comprised of twelve questions and assessed on the first study visit. LWDS values range from 0 to 36 where higher sores indicate greater nicotine dependence.
Time frame: Baseline
General Harm and Health Risk Perceptions
Assessed using harm/health risk perceptions questionnaire. General harm is rated after the smoking session on a scale from 0 (no harm) to 10 (extreme harm) with higher scores indicating a greater perceived harm/health risk.
Time frame: Post Smoking Session
Subjective Effects of Smoking Tobacco
Direct Effects of Tobacco scale; the scale for each effect ranges from 0 (not at all) to 100 (extremely) with higher ratings indicating a greater effect of the tobacco.
Time frame: Post Smoking Session
Change in Subjective Effects of Smoking Tobacco - Direct Effects of Nicotine
Change in Direct Effects of Nicotine scale from baseline (post - pre). The scale for each effect ranges from 0 (not at all) to 100 (extremely) with higher ratings indicating a greater effect of the tobacco.
Time frame: Approximately 30 to 90 minutes
Change in Subjective Effects of Smoking Tobacco (QSU)
Change from baseline Questionnaire for Urges to Smoke (post - pre). This is a 10-item measure where participants rate smoking-related items on a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). Items are collapsed into two previously identified factors (Factor 1: strong desire and intention to smoke; Factor 2: anticipation of relief from withdrawal symptoms). Scores are calculated by summing the items and range from 5 to 30 with higher scores indicating greater urge to smoke.
Time frame: Approximately 30 to 90 minutes
Change in Nicotine Withdrawal Assessment (MNWS)
Change from baseline using Waterpipe-modified Minnesota Withdrawal Scale (post - pre). The scale ranges from 0 (not at all) to 100 (extremely) with higher total numbers meaning greater withdrawal symptoms.
Time frame: Approximately 30 to 90 minutes
Tobacco Flavor Perception (gLMS)
To determine the relative intensity of specific flavors, e.g., sweetness, the general version of the Labeled Magnitude Scale (gLMS) was used post-smoking session. The scale ranges from 0 to 100 where higher scores indicate that the perception is stronger.
Time frame: Post Smoking Session
Tobacco Flavors Perception, Degree of Liking or Disliking (LHS)
To assess the degree of liking or disliking of flavors, will use the Labeled Hedonic Scale (LHS) to collect ratio-level data on the magnitude of liking and disliking of sensation post-smoking session. Scores range from 0 to 100 with higher scores indicating greater liking.
Time frame: Post Smoking Session
Puffing Topography - Puff Volume
Puff volume measured continuously during the smoking session using the research-grade waterpipe.
Time frame: Up to 60 minutes
Puffing Topography - Puff Duration
Puff duration measured continuously during the smoking session using the research-grade waterpipe.
Time frame: Up to 60 minutes
Puffing Topography - Flow Rate
Puffing average flow rate measured continuously during the smoking session using the research-grade waterpipe.
Time frame: Up to 60 minutes
Puffing Topography - Peak Flow Rate
Puffing peak flow rate measured continuously during the smoking session using the research-grade waterpipe.
Time frame: Up to 60 minutes
Puffing Topography - Interpuff Interval
Interpuff interval measured continuously during the smoking session using the research-grade waterpipe.
Time frame: Up to 60 minutes
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