Bronchoscopy in Determining the Effect of E-Cigarette Smoking on Biomarkers in the Lungs

Study Overview
=================
Brief Summary
-----------------
This trial studies biomarkers obtained by bronchoscopy (bronchoalveolar lavage and lung brushings) to determine the effect of smoking e-cigarettes on the lungs. Studying samples of lung cells from participants who smoke e-cigarettes may help doctors learn more about changes that occur in deoxyribonucleic acid and identify biomarkers related to cancer.

Detailed Description
-----------------
PRIMARY OBJECTIVES: I. To assess inflammatory changes over 10 weeks for lung and urine biomarkers in smokers who undergo serial bronchoscopy. The randomized trial includes four conditions: continued use (n=32), complete switching to the nicotine standardized research electronic cigarettes (e-cig) (SREC) (n=32), complete switching to the placebo (nicotine free) SREC (n=32), and complete switching to nicotine replacement therapy (NRT)(n=32). OUTLINE: Participants are randomized to 1 of 4 groups. GROUP I: Participants undergo bronchoscopy over 30-60 minutes at baseline. Participants continue to smoke their usual brand of cigarettes. Participants undergo a second bronchoscopy on day 71. GROUP II: Participants undergo bronchoscopy over 30-60 minutes at baseline. After the baseline bronchoscopy, participants learn to use the SREC with nicotine for 2 weeks and switch completely to the SREC with nicotine for 2 weeks and switch completely to the SREC with nicotine starting day 15 for 8 weeks. Participants undergo a second bronchoscopy on day 71. GROUP III: Participants undergo bronchoscopy over 30-60 minutes at baseline. After the baseline bronchoscopy, participants learn to use the SREC without nicotine for 2 weeks and switch completely to the SREC without nicotine starting day 15 for 8 weeks. Participants will be offered varenicline to aid cessation. Participants undergo a second bronchoscopy on day 71. GROUP IV: Participants undergo bronchoscopy over 30-60 minutes at baseline. Beginning 1 week before the day 15 quit date, participants stop smoking using NRT comprising either patch, gum, or lozenge for 8 weeks. Participants undergo a second bronchoscopy on day 71. After completion of study, participants are followed up at 3 months.

Official Title
-----------------
The Effects of a Standardized Research E-Cigarette on the Human Lung: A Clinical Trial With Bronchoscopic Biomarkers

Conditions
-----------------
Cigarette Smoker, Current Every Day Smoker

Intervention / Treatment
-----------------
* Procedure: Bronchoscopy with Bronchoalveolar Lavage
* Drug: Cigarette
* Other: Electronic Cigarette
* Other: Electronic Cigarette
* Other: Laboratory Biomarker Analysis
* Drug: Nicotine Replacement
* Other: Questionnaire Administration


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Smokers who smoke >= 5 filtered cigarettes/day for >= 1 year No unstable or significant medical conditions as determined by medical history to ensure safety of the subject, to minimize the effects of poor health on biomarker measures and to maximize compliance to study procedures Able to read adequately to complete the survey and related study documents or give consent Subject has provided written informed consent to participate in the study Exclusion Criteria: Regular consumption of roll your own cigarettes Immune system disorders requiring medication Prior diagnosis of chronic pulmonary disease (e.g., asthma with regular use of medications, chronic obstructive pulmonary disease [COPD], chronic bronchitis, and restrictive lung disease) Acute bronchitis or pneumonia within 1 year Reported history of diagnosed kidney or liver disease Any medical disorder that will increase the risk from bronchoscopy, affect biomarker data, or increase risk of an adverse effect from e-cig use General anesthesia within 1 year Regular use of inhalant medications in the last 2 months Use of antibiotics in prior 30 days Use of steroids, including corticosteroids, in prior 30 days Allergies to study medications, such as, lidocaine, Versed, fentanyl or Cetacaine Allergies to propylene glycol/glycerin or flavors History of hypersensitivity to varenicline Bronchoscopy or any other lung procedure for any reason within the previous 6 months Current or recent (within three months) alcohol or drug abuse problems Regularly smoked marijuana within the prior 3 months Use of an e-cigarette or other combustible tobacco products in the prior 3 months Currently using nicotine replacement or other tobacco cessation products (to minimize confounding effects of another product) or intention to quit in next three months Adverse reaction to previous e-cig use Body mass index (BMI) > 40 (risk of unstable airway) Pregnant or breastfeeding - if the subject is female, a urine pregnancy test at no cost to the subject will be done on the day of bronchoscopy Unable to read for comprehension or completion of study documents

Ages Eligible for Study
-----------------
Minimum Age: 21 Years
Maximum Age: 52 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
Accepts Healthy Volunteers

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Group I (usual cigarette brand)<br>Participants undergo bronchoscopy over 30-60 minutes at baseline. Participants continue to smoke their usual brand of cigarettes. Participants undergo a second bronchoscopy on day 71. | Procedure: Bronchoscopy with Bronchoalveolar Lavage<br>* Undergo bronchoscopy with bronchoalveolar lavage<br>* Other names: Bronchoscopy/Lavage;Drug: Cigarette<br>* Smoke usual brand<br>Other: Laboratory Biomarker Analysis<br>* Correlative studies<br>Other: Questionnaire Administration<br>* Ancillary studies<br>|
| Experimental: Group II (SREC with nicotine)<br>Participants undergo bronchoscopy over 30-60 minutes at baseline. After the baseline bronchoscopy, participants learn to use the SREC with nicotine for 2 weeks and switch completely to the SREC with nicotine starting day 15 for 8 weeks. Participants undergo a second bronchoscopy on day 71. | Procedure: Bronchoscopy with Bronchoalveolar Lavage<br>* Undergo bronchoscopy with bronchoalveolar lavage<br>* Other names: Bronchoscopy/Lavage;Other: Electronic Cigarette<br>* Smoke SREC with nicotine<br>* Other names: Electronic Nicotine Delivery System;Other: Laboratory Biomarker Analysis<br>* Correlative studies<br>Other: Questionnaire Administration<br>* Ancillary studies<br>|
| Experimental: Group III (SREC without nicotine)<br>Participants undergo bronchoscopy over 30-60 minutes at baseline. Beginning 1 week after bronchoscopy, participants learn to use the SREC without nicotine for 2 weeks and switch completely to the SREC without nicotine starting day 15 for 8 weeks. Participants will be offered varenicline to aid cessation. Participants undergo a second bronchoscopy on day 71. | Procedure: Bronchoscopy with Bronchoalveolar Lavage<br>* Undergo bronchoscopy with bronchoalveolar lavage<br>* Other names: Bronchoscopy/Lavage;Other: Electronic Cigarette<br>* Smoke SREC without nictoine<br>* Other names: Electronic Nicotine Delivery System;Other: Laboratory Biomarker Analysis<br>* Correlative studies<br>Other: Questionnaire Administration<br>* Ancillary studies<br>|
| Experimental: Group IV (Nicotine Replacement Therapy [NRT])<br>Participants undergo bronchoscopy over 30-60 minutes at baseline. One week before the day 15 quit date, participants stop smoking using NRT comprising either patch, gum, or lozenge for 8 weeks. Participants undergo a second bronchoscopy on day 71. | Procedure: Bronchoscopy with Bronchoalveolar Lavage<br>* Undergo bronchoscopy with bronchoalveolar lavage<br>* Other names: Bronchoscopy/Lavage;Other: Laboratory Biomarker Analysis<br>* Correlative studies<br>Drug: Nicotine Replacement<br>* Receive NRT comprising patch, gum, or lozenge<br>* Other names: NRT;Other: Questionnaire Administration<br>* Ancillary studies<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in cell counts and cytokines | Obtained via bronchoscopy with saline bronchoalveolar lavage (BAL) and bronchial brushings. Descriptive statistics and clustering (e.g., principal components analysis [PCA]), will be performed for all biomarker data measured at the different visits. Baseline data (1st bronchoscopy) will then be compared between the four groups (3 conditions and control) using a one-way analysis of variance (ANOVA). The non-parametric Kruskal-Wallis test (continuous or ordinal variables) or the chi-square test (categorical variables) will be applied when the normality assumption of the data is not met. Controls will be compared to complete substitution with the standardized research electronic cigarettes (SREC) (with and without nicotine) or nicotine replacement therapy (NRT. Generalized linear models (GLM) will be employed with measurement (cell count, gene expression, etc.) as the dependent variable, a covariable for baseline measure, and a main effect of arm. | Baseline to day 71 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in fractional exhaled nitric oxide (FeNO) levels | FeNO will be measured with the NIOX VERO. Descriptive statistics and clustering (e.g. PCA), will be performed for all biomarker data measured at the different visits. Baseline data (1st bronchoscopy) will then be compared between the four groups (3 conditions and control) using a one-way ANOVA. The non-parametric Kruskal-Wallis test (continuous or ordinal variables) or the chi-square test (categorical variables) will be applied when the normality assumption of the data is not met. Controls will be compared to complete substitution with the SREC (with and without nicotine) or NRT. GLM will be employed with measurement (cell count, gene expression, etc.) as the dependent variable, a covariable for baseline measure, and a main effect of arm. | Baseline up to day 71 | 
| Changes in messenger (m) ribonucleic acid (RNA) and microRNA (miRNA) gene expression analyzed using sequencing | Total RNA containing small RNAs will be extracted from bronchial brushing specimens using commercially available kits and used for both gene expression using the Affymetrix GeneChip Human Transcriptome Array and for miRNA expression using the Affymetrix GeneChip miRNA Array. Expression will separately be assessed through RNA sequencing. Total RNA will be extracted from lavage cells and saliva for comprehensive profiling of microbiome using commercially available kits. The ?omics? (miRNA, mRNA, and metabolomics) analysis and visualization of the data will be performed in the R statistical language. Data will be log2-transformed and normalized using either quantile normalization for gene expression (miRNA and mRNA) or normalization for metabolomics. Unsupervised clustering analysis, including PCA and hierarchical clustering will be performed to visualize natural clusters in the dataset and evaluate data quality. | Baseline up to day 71 | 
| Changes in deoxyribonucleic acid (DNA) gene methylation | Total DNA will be extracted using commercially available kits and used for genome-wide DNA methylation profiling. Total DNA including mitochondrial DNA (mtDNA) will be extracted using commercially available kits and used for mtDNA mutation using Hiseq Next Generation Sequencing (NGS) and for mtDNA contents using quantitative polymerase chain reaction (qPCR). For preliminary identification of patterns in DNA methylation, unsupervised hierarchical clustering among the groups of samples will be performed. The Euclidian distance among the groups of samples will be calculated by the average linkage. In order to assess variance among samples, PCA will be done. | Baseline up to day 71 | 
| Changes in the microbiome in BAL cells and saliva | Obtained via bronchoscopy with saline BAL and bronchial brushings. Samples will be analyzed to determine their bacterial composition. | Baseline up to day 71 | 
| Changes in untargeted metabolomics using mass spectrometry | Obtained via bronchoscopy with saline BAL and bronchial brushings. The omics (miRNA, mRNA, and metabolomics) analysis and visualization of the data will be performed in the R statistical language. Data will be log2-transformed and normalized using either quantile normalization for gene expression (miRNA and mRNA) or normalization for metabolomics. Unsupervised clustering analysis, including PCA and hierarchical clustering will be performed to visualize natural clusters in the dataset and evaluate data quality. | Baseline up to day 71 |