Philip Morris International R&D, Philip Morris Products S.A., Switzerland. 2

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1 Comparative assessment of lung inflammation, pulmonary function and emphysema caused by the aerosol from potential Reduced Risk Products and cigarette smoke in mouse models of COPD. 11 July, 216 COPD Brisbane Patrick Vanscheeuwijck 1, Blaine Phillips 2, Ee Tsin Wong 2, Julia Hoeng 1, Manuel C. Peitsch 1 1 Philip Morris International R&D, Philip Morris Products S.A., Switzerland. 2 Philip Morris International R&D, Philip Morris International Research Laboratories Pte Ltd, Singapore Philip Morris International is the sole source of funding and sponsor of this project.

2 PMI s Goal for Harm Reduction Offering adult smokers satisfying products that reduce risk Smoking is addictive and causes a number of serious diseases Worldwide it is estimated that more than one billion people will continue to smoke in the foreseeable future PRODUCT REDUCED-RISK ACCEPTANCE AND PRODUCT X = USAGE HARM REDUCTION Successful harm reduction requires that current adult smokers be offered a range of Reduced Risk Products (RRPs) so that consumer acceptance can be best fulfilled The Tobacco Atlas 3 rd Edition. American Cancer Society, 29 Figure adapted from Clive Bates presentation to E-Cigarette Summit (19 Nov 213)

3 Reduced-Risk Products ( RRPs ) is the term the company uses to refer to products with the potential to reduce individual risk and population harm in comparison to smoking cigarettes. PMI s RRPs are in various stages of development and commercialization, and we are conducting extensive and rigorous scientific studies to determine whether we can support claims for such products of reduced exposure to harmful and potentially harmful constituents in smoke, and ultimately claims of reduced disease risk, when compared to smoking cigarettes. Before making any such claims, we will rigorously evaluate the full set of data from the relevant scientific studies to determine whether they substantiate reduced exposure or risk. Any such claims may also be subject to government review and authorization as is the case in the US today.

4 Aim and scope of the presentation Assessment of the effects of cigarette smoke and a RRP (THS2.2), using PMI s Heat-not-Burn technology, in 2 animal models of COPD: ApoE -/- mouse (C57Bl6 background), typically used as model for cardiovascular disease A/J mouse, used as model for lung cancer Both animal models are responsive to cigarette mainstream smoke and develop different pathologies, among which aspects of COPD such as lung inflammation, changed pulmonary function, emphysema Other endpoints, such as general (chronic) toxicity, atherosclerosis, lung tumor development determined in these studies will not be reported here Lo Sasso G, Schlage WK, Boué S, Veljkovic E, Peitsch MC, Hoeng J. (216) The Apoe(-/-) mouse model: a suitable model to study cardiovascular and respiratory diseases in the context of cigarette smoke exposure and harm reduction. J Transl Med (1):146.Epub. Review. PMID Stinn W, Buettner A, Weiler H, Friedrichs B, Luetjen S, van Overveld F, Meurrens K, Janssens K, Gebel S, Stabbert R, Haussmann HJ. (213) Lung inflammatory effects, tumorigenesis, and emphysema development in a long-term inhalation study with cigarette mainstream smoke in mice. Toxicol Sci. 131(2): PMID:

5 Common disease mechanisms in different mouse models, relevance to human situation Possible interrelationships and roles for the identified common mechanisms (HYPs) in five mouse models of emphysema in a framework of classical human COPD mechanisms. transcription factors (black font) inflammatory mediators (orange font) classical pathways of human COPD pathogenesis (black arrows) as depicted, From: Cabanski M, Fields B, Boue S, Boukharov N, DeLeon H, Dror N, Geertz M, Guedj E, Iskandar A, Kogel U, Merg C, Peck MJ, Poussin C, Schlage WK, Talikka M, Ivanov NV, Hoeng J, Peitsch MC. (215): Transcriptional profiling and targeted proteomics reveals common molecular changes associated with cigarette smokeinduced lung emphysema development in five susceptible mouse strains. Inflamm Res.64(7): PMID:

6 Methods Cigarette smoke and aerosol from a RRP Assessment of smoke/aerosol Health Canada Intense smoke protocol Conventional cigarettes: Smoke from University of Kentucky Standard Reference Cigarette Potentially Reduced-Risk product: Aerosol generated by Tobacco Heating System, commercialized as iqos (also designated as THS 2.2)

7 [Disease Risk] ApoE -/- mouse switching study Study design Comparative assessment of effects of THS2.2 and Switching design upon initiation of disease: to assess reversibility (switch to fresh air, i.e. cessation) and To quantify how similar switching to THS2.2 is to cessation Point of intervention Groups SWITCHING CESSATION Control: Sham/Air THS2.2 Start Inhalation THS2.2 Fresh Air Fresh Air THS2.2 Month 2 Month 8 [Time] Dissection time points: Month 1, 2, 3, 6 and 8 7

8 N ic o tin e c o n c e n tr a tio n g /l + /- S D ApoE -/- mouse switching study Methods - Exposure regime Fresh air 4 Nicotine concentration in exposure chamber (study average) THS2.2 or - Animals were exposed 3 hours per day (3 x 1 hour interrupted exposure periods), 5 days per week - Nicotine was measured during every exposure period (3 samples per chamber per day) - Aerosol delivery (nicotine) was within +/- 1% of the targeted 29.9 µg/l nicotine concentration 29.9 µg/l nic corresponds to 6.5 mg/kg, daily dose- or the nicotine amount from approx. 32 cig/day for a 6 kg human, based on body surface comparison, Guidance document Heq dose, FDA R 4 F 8

9 ApoE -/- mouse switching study Aerosol uptake (biomarkers of exposure) Plasma Nicotine (month 8) HPMA (Acrolein metabolite) Urinary Metabolites (months 3, 6, 8) CEMA (Acrylonitrile metabolite) Air THS2.2 Cess. Swit. Means ± SEM NNAL (NNK metabolite) SPMA (Benzene metabolite) Groups Cessation Switching THS2.2 Sham / Air Means ± SEM 9

10 N e u tro p h ils (x 1 5 ) + /- S E M L y m p h o c y te s (x 1 5 ) + /- S E M A lv e o la r m a c ro p h a g e s (x 1 5 ) + /- S E M A lv e o la r d e n d ritic c e lls (x 1 5 ) + /- S E M ApoE -/- mouse switching study Result summary: Disease mechanisms - Lung inflammation Free lung cells in Broncho-alveolar lavage fluid (BALF) Total Cells (x 1 5 ) +/- SEM Total cells absolute Sham THS 2.2 Cessation Switch Differential counts A lv e o la r m a c ro p h a g e s a b s o lu te A lv e o la r d e n d ritic c e lls a b s o lu te R 4 F TH S 2.2 C e s s a tio n S w itc h R 4 F TH S 2.2 C e s s a tio n S w itc h N e u tro p h ils a b s o lu te L y m p h o c y te s a b s o lu te 8 5 TH S 2.2 S w itc h S w itc h 3 R 4 F C e s s a tio n 3 R 4 F C e s s a tio n 4 6 Groups Cessation Switching THS2.2 Sham / Air Study month Study month 1

11 U n p ig m e n te d m a c ro p h a g e s in a lv e o la r lu m e n M e a n s c o r e + /- S E M ApoE -/- mouse switching study Result summary: Histopathology of the lung Pulmonary inflammation Results, Lung Inflammation unpigmented macrophages in the alveolar lumen Groups Cessation Switching THS2.2 Sham / Air sham THS2.2 Cessation Switch S tu d y m o n th : Statistically significant compared to sham : Statistically significant compared to :CONT at month 2 Decrease in mean scores after switching to fresh air or THS2.2 (statistically significant from month 6) No statistically significant difference between Cessation group and THS2.2-Switch group at month 3 11

12 M M P a c tiv ity (m U /m l) + /- S D ApoE -/- mouse switching study Result summary: Disease mechanisms - Lung inflammation Multiple analyte profiling in Broncho-alveolar Lavage Fluid THS2.2 Cess. Switch 3 M M P a c tiv ity Groups Cessation Switching THS2.2 Sham / Air M o n th 12

13 V p l (m l) + /- S E M V p l (m l) + /- S E M V p l (m l) + /- S E M V p l (m l) + /- S E M D is p la c e d liq u id w e ig h t (g ) ApoE -/- mouse switching study Result summary: Disease endpoints- Lung function and lung volume Lung function: Pressure Volume Loops (PVsP) (FlexiVent (Scireq)) M o n th 2 3 R 4 FMonth R 4 F M o n th 3 Month 3 C e s s a tio n S w itc h Groups Cessation Switching THS2.2 Sham / Air L u n g v o lu m e (a b s o lu te, m e a s u re d ) S w itc h 3 R 4 F C e s s a tio n R 4F P p l (c m H 2 O ) M o n th 6 C essation S w itc h R 4 F P p l (c m H 2 O ) M o n th 8 Month 6 Month 8 C e s s a tio n S w itc h M o n th P p l (c m H 2 O ) P p l (c m H 2 O ) Means ± SEM 13

14 A lv e o la r e m p h y s e m a + /- S E M Switching Study in an Animal Model of Disease Result summary: Tissue changes Histopathology Histopathological Assessment emphysema Groups Cessation Switching THS2.2 Sham / Air sham THS2.2 Cessation Switch S tu d y m o n th : Statistically significant compared to sham : Statistically significant compared to :CONT at month 2 14

15 B r o n c h io la r a tta c h m e n ts + /- S E M M e a n c o r d le n g th (u m ) + /- S E M D e s tru c tiv e in d e x (e m p h y s e m a to u s tis s u e (% ) + /- S E M ApoE -/- mouse switching study Result Summary: Lung tissue changes Morphometry Groups Cessation Switching THS2.2 Sham / Air S tu d y m o n th S tu d y m o n th S tu d y m o n th Bronchiolar attachments - Fewer Bronchiolar attachments in -exposed group Mean chord length (MCL) - Mean linear intercept length - Increased MCL in exposed group Destructive index (DI) - Index of parenchymal destruction - Increased DI in -exposed group 15

16 Down regulated -log 1 (p value) Up regulated ApoE -/- mouse switching study Result Summary: Systems response profile: differential gene expression - Lung Cessation Switch q =.5 log 2 (fold change) THS2.2 16

17 ApoE -/- mouse switching study Result Summary: Disease mechanisms - Network perturbations - Lung Cessation Switch Cell proliferation Tissue repair Inflammation Senescence DNA damage Apoptosis Cell stress THS2.2 17

18 Switching Study in an Animal Model of Disease Summary and Conclusions The ApoE -/- mouse model is suitable for studying smoke-related aspects of COPD Continuous exposure to smoke from causes lung inflammation, lung function and emphysematous changes as of one month of treatment Continuous exposure to aerosol from THS2.2 for up to 8 months does not increase inflammation and emphysema in comparison to Sham group Switching from cigarette smoke exposure after 2 months to fresh air (Sham) exposure reverses the onset of disease as measured in apical, functional, and molecular endpoints Switching from cigarette smoke exposure to THS2.2 aerosol exposure reverses the onset of disease in a similar manner as cessation Phillips B, Veljkovic E, Boué S, Schlage WK, Vuillaume G, Martin F, Titz B, Leroy P, Buettner A, Elamin A, Oviedo A, Cabanski M, De León H, Guedj E, Schneider T, Talikka M, Ivanov NV, Vanscheeuwijck P, Peitsch MC, Hoeng J. (216). An 8-Month Systems Toxicology Inhalation/Cessation Study in Apoe-/- Mice to Investigate Cardiovascular and Respiratory Exposure Effects of a Candidate Modified Risk Tobacco Product, THS 2.2, Compared With Conventional CigarettesToxicol Sci. 149(2): PMID Titz, B., Boue, S., Phillips, B., Talikka, M., Vihervaara, T., Schneider, T., Nury, C., Elamin, A., Guedj, E., Peck, M.J., Schlage WK, Cabanski M, Leroy P, Vuillaume G, Martin F, Ivanov NV, Veljkovic E, Ekroos K, Laaksonen R, Vanscheeuwijck P, Peitsch MC, Hoeng J.(216). Effects of Cigarette Smoke, Cessation, and Switching to Two Heat-Not-Burn Tobacco Products on Lung Lipid Metabolism in C57BL/6 and Apoe-/- Mice-An Integrative Systems Toxicology Analysis. Toxicol Sci 149, PMID Lo Sasso, G., Titz, B., Nury, C., Boue, S., Phillips, B., Belcastro, V., Schneider, T., Dijon, S., Baumer, K., Peric, D, Dulize R, Elamin A, Guedj E, Buettner A, Leroy P, Kleinhans S, Vuillaume G, Veljkovic E, Ivanov NV, Martin F, Vanscheeuwijck P, Peitsch MC, Hoeng J. (216). Effects of cigarette smoke, cessation and switching to a candidate modified risk tobacco product on the liver in Apoe / mice a systems toxicology analysis. Inhal Toxicol. 28(5): PMID Lo Sasso G, Schlage WK, Boué S, Veljkovic E, Peitsch MC, Hoeng J. (216) The Apoe(-/-) mouse model: a suitable model to study cardiovascular and respiratory diseases in the context of cigarette smoke exposure and harm reduction. J Transl Med (1):146.Epub. Review. PMID

19 A/J mouse study Study design (OECD TG 453 Chronic toxicity) BALF analysis Lung function Biomarkers of exposure, hematology, blood FACS, clinical chemistry, urinalysis Biomarkers of exposure, blood FACS, urinalysis Omics Histopathology Omics Histopathology 19

20 N ic o tin e ( g /l), m e a n + /- S D T o t a l N i c o t i n e M e t a b o l i t e s ( n m o l, m e a n + / - S E M ) A/J mouse study Methods - Exposure and aerosol uptake - Animals were exposed 6 hours per day, 5 days per week - Nicotine was measured 3 samples per chamber per day) - Aerosol delivery (nicotine) was within +/- 1% of the targeted nicotine concentration - Aerosol uptake was in line with test atmosphere nicotine concentration Nicotine concentration in exposure chamber (study average) Nicotine metabolites in urine 3 R 4 F T H S 2. 2 T H S 2. 2 T H S 2. 2 T H S 2. 2 L o w M e d H ig h H ig h L o w M e d H i g h H i g h F e m a le M a l e F e m a l e M a l e 26.8 µg/l nic (high dose) corresponds to 11.6 mg/kg, daily dose- or the nicotine amount from approx. 56 cig/day for a 6 kg human, based on body surface comparison, Guidance document Heq dose, FDA 2

21 T L y m p h o c y t e C o u n t (1 5, m e a n + /-S E M ) B L y m p h o c y t e C o u n t (1 5, m e a n + /-S E M ) T o ta l C e ll C o u n t (1 5, m e a n + /-S E M ) N e u t r o p h il C o u n t (1 5, m e a n + /-S E M ) A/J mouse study Result summary: Inflammation - Free lung cell analysis in BALF exposure-related increases in neutrophil, alveolar macrophage, dendritic cell, and lymphocyte count No obvious increase in the immune cell counts in lungs (BALF) of THS2.2 aerosol-exposed mice M o n th 1 M o n th L o w M e d H ig h L o w M e d H ig h 3.4 M o n th 1 M o n th 1 M o n th 5.3 M o n th R 4F L o w M e d H ig h 3R 4F L o w M e d H ig h 21

22 A/J mouse study Result summary: Lung inflammation BALF cytokines/chemokines Minimal up-regulation of key inflammatory factors in THS2.2 aerosol-exposed mice exposure-related increases in Levels of inflammatory cytokines, e.g. IL-6, TNF-a, IL1-b Levels of chemotactic factors, e.g. MCP1, KC Growth factors, e.g. EGF, VEGF 22

23 A/J mouse study Result summary: Lung function No obvious changes in lung function in THS2.2 aerosol-exposed mice Lung function Flexivent - Pressure- Volume loops Month 1 THS2.2 Month 1 exposure-related changes Leftward & upward shift of the P-V loops for both the inflation and deflation phases Increased lung volumes at specified pressure; greater ease with which the lungs may be extended at a specified pressure Month 5 Month 5 Lower pressure at specified volume of air in the lung THS2.2 23

24 M e a n C h o r d L e n g t h m e a n ± S E M ( m ) D e s t r u c t i v e i n d e x m e a n ± S E M ( % ) B r o n c h i o l a r a t t a c h m. m e a n ± S E M ( n /m m ) S e v e r i t y s c o r e m e a n ± S E M A/J mouse study Result summary: Lung tissue changes Histopathology and morphometry Histopathology - emphysema Histopathological assessment and morphometric analysis shows consistent emphysema in -exposed A/J mice but in THS2.2-exposed animals M o n th 1 M o n th 5 M o n th 1 1 Morphometry Mean Chord Length Month Morphometry Destructive index Month R 4 F 3 R 4 F L o w L o w M e d M e d H ig h Morphometry Bronchiolar attachments Month 5 H ig h R 4 F 3 R 4 F L o w L o w M e d M e d H ig h p<.5; p<.1; p<.1 differences relative to sham H ig h 3 R 4 F 3 R 4 F L o w L o w M e d M e d H ig h H ig h 3 R 4 F 3 R 4 F L o w L o w M e d M e d H ig h H ig h 24

25 A l v. s u r f. d e n s it y s e p t u m (n /m m ) N u m. d e n s. a l v e o li p a r. ( n ) t o t a l n o. a l v e o l i A/J mouse study Result summary: Lung tissue changes Morphometry Supplemental analysis of lung volume-independent state-of-the-art morphometric parameters confirm the emphysematous changes in -exposed but in the THS2.2-exposed mice 4 Morphometry Alveolar surface density in septum Month 5 4 Morphometry Numerical density of alveoli in parenchyma Month 5 4 Morphometry Total number of alveoli Month R 4 F 3 R 4 F L o w L o w M e d M e d H ig h H ig h 3 R 4 F 3 R 4 F L o w L o w M e d M e d H ig h H ig h 3 R 4 F 3 R 4 F L o w L o w M e d M e d H ig h H ig h p<.5; p<.1; p<.1 differences relative to sham 25

26 A/J mouse study Summary and Conclusions The A/J mouse model is suitable for studying smoke-related aspects of COPD After 1 month of exposure to cigarette smoke, lung inflammation is clearly present and changes in lung function are obvious lung emphysema is present at the 5 months time point Exposure to aerosol for THS2.2 doesn t cause any changes in lung inflammation, lung function and emphysema Stinn W, Buettner A, Weiler H, Friedrichs B, Luetjen S, van Overveld F, Meurrens K, Janssens K, Gebel S, Stabbert R, Haussmann HJ. (213) Lung inflammatory effects, tumorigenesis, and emphysema development in a long-term inhalation study with cigarette mainstream smoke in mice. Toxicol Sci. 131(2): PMID:

27 Comparison mouse models Both independent mouse studies have shown that: Lung inflammation and changes in pulmonary function are induced after 1 month of exposure to cigarette smoke Lung emphysema is caused by cigarette smoke and significant after 2 months (or 5 months A/J mice) of exposure to cigarette smoke Aerosol from THS2.2, a RRP, causes only minimal changes in lung inflammation, but no changes in lung function and pulmonary emphysema. 27

28 THANK YOU 28