It is critical that applicants follow the Research (R) Instructions in the SF424 (R&R) Application Guide, except where instructed to do otherwise (in this FOA or in a Notice from the NIH Guide for Grants and Contracts). Conformance to all requirements (both in the Application Guide and the FOA) is required and strictly enforced. Applicants must read and follow all application instructions in the Application Guide as well as any program-specific instructions noted in Section IV. When the program-specific instructions deviate from those in the Application Guide, follow the program-specific instructions. Applications that do not comply with these instructions may be delayed or not accepted for review.

Part 1. Overview Information
Part 2. Full Text of the Announcement

Section I. Funding Opportunity Description
Section II. Award Information
Section III. Eligibility Information
Section IV. Application and Submission Information
Section V. Application Review Information
Section VI. Award Administration Information
Section VII. Agency Contacts
Section VIII. Other Information

Purpose

This Funding Opportunity Announcement (FOA) invites applications investigating the cellular and molecular mechanisms by which alcohol increases cancer risk.

Alcohol consumption is classified as carcinogenic to humans by the International Agency for Research on Cancer (IARC; 2010, 2012) and the National Toxicology Program (NTP; 2014) of the US Department of Health and Human Services. Target sites for alcohol-related carcinogenesis include the upper aerodigestive tract, breast, liver, and colon. A better understanding of the molecular basis by which alcohol increases cancer risk for certain tissues and organs could lead to improved therapeutic approaches and preventative strategies and would provide guidance on safe levels of alcohol consumption.

Related Funding Opportunity: Investigators interested in proposing exploratory and developmental research projects should submit applications in response to the partner FOA of identical scientific scope (PA-17-219), which uses the NIH R21 grant mechanism.

Background

1. Epidemiology of alcohol-related cancers

Worldwide, 3.6% of all cancers are attributable to alcohol, totaling 390,000 cases annually. Cumulative epidemiological evidence supports the conclusion that certain cancers are associated with alcohol consumption, with the relative risk of cancer often varying with the amount of alcohol consumed.

Upper aerodigestive tract cancers

Cancers of the upper aerodigestive tract (UADT), sometimes referred to as head and neck cancers, include cancers of the pharynx, larynx, esophagus and the oral cavity. The relative risk of UADT cancers is increased slightly with consumption of two drinks per day, but rises to 4-6 fold with heavier drinking. Moreover, the risk of developing UADT cancer when alcohol and tobacco are used in combination is much higher than the additive risk of smoking or of alcohol intake separately. Genetic variations in alcohol metabolizing enzymes have a profound effect on UADT cancer risk, implicating alcohol or its metabolites in the development of these cancers.

Hepatocellular carcinoma

Multiple risk factors contribute to the genesis of hepatocellular carcinoma, including alcohol consumption, viral infections, obesity and diabetes. Fully twenty-five per cent of hepatocellular carcinoma cases are associated with alcoholic liver disease. While much is known about the progression of alcoholic liver disease, from steatosis or fatty liver to steatohepatitis to fibrosis to cirrhosis, much more remains to be learned about the progression to hepatocellular carcinoma and how alcohol influences this process. In addition, hepatitis B virus (HBV) and hepatitis C virus (HCV) are major contributors to the incidence of hepatocellular carcinoma. The combined insults of HBV or HCV and alcohol increase cancer incidence synergistically.

Breast cancer

Alcohol consumption in post-menopausal women raises the risk of breast cancer up to three-fold in a dose dependent manner. However, the relationship in pre-menopausal women is more subtle. Meta-analyses suggest a linear correlation between the amount of alcohol consumed and breast cancer incidence in women, with each 10 gram intake of alcohol increasing breast cancer incidence by 7% on average. However, surveys of alcohol consumption are based on self-report and often fail to distinguish moderate drinking from binge drinking. This is important because different patterns of alcohol consumption may have significantly different biochemical consequences. In addition, recent evidence suggests that specific sub-types of estrogen receptor positive breast cancer correlate with alcohol consumption. Thus, further study of the linkage of alcohol consumption with elevated breast cancer risk, and of the molecular characteristics of the alcohol-associated cancers, will be informative.

Colon cancer

A significant fraction of colon cancers is attributable to alcohol with men more affected than women. Understanding the mechanism of colon cancer development would help distinguish whether the sex disparity is caused by differences in alcohol consumption or physiology. More importantly, identifying the molecular perturbations caused by alcohol may provide a target for therapeutic intervention.

Pancreatic cancer

The association between alcohol consumption and pancreatic cancer risk remains unclear. Some studies suggest a modest increase in risk association only with heavy drinking but not low to moderate consumption, which may be modified by gender and smoking status.

Thyroid cancer

Intriguingly, moderate alcohol consumption is associated with a slight reduction in the incidence of thyroid cancer. The mechanistic basis for this observation is not yet known.

2. Cellular and molecular processes altered by alcohol

Some of the myriad pathways and processes altered by alcohol or its metabolites and implicated in modulating the initiation, promotion, progression or metastasis of tumors are discussed here. The following is not meant to be a complete list of candidate pathways. Characterization of the cellular and molecular processes that are disrupted by exposure to alcohol is necessary to understanding its pathological effects. Alcohol alters biological function directly by interacting with cellular components and indirectly by metabolites influencing systemic oxidative and inflammatory states.

2A. Mutagenic potential of alcohol and alcohol metabolism

Metabolites of alcohol may contribute to the initiation of cancer. Acetaldehyde, the first metabolite of alcohol, has also been designated by the IARC as a human carcinogen. Several lines of evidence support a role for acetaldehyde in cancer initiation. Acetaldehyde is reactive, forming DNA-acetaldehyde adducts that can incorporate into the genome, leading to mutagenesis, and transformation of healthy cells into tumor cells. Genetic evidence also supports a role for alcohol metabolism in cancer risk, particularly in esophageal cancer, since variants in alcohol and aldehyde metabolizing enzymes increase susceptibility to cancer after alcohol consumption.

In addition, alcohol metabolism results in the production of reactive oxygen (ROS) and reactive nitrogen species, resulting in oxidative stress. Oxidative stress and consequent inflammatory environments are damaging to healthy host tissue, and have been linked to the development of cancer. Chronic alcohol consumption leads to systemic and tissue localized chronic inflammation. In addition, chronic alcohol consumption results in the induction of cytochrome P4502E1 (CYP2E1), which, in addition to metabolizing ethanol, generates ROS and lipid peroxidation products that can directly damage DNA. CYP2E1 can also convert procarcinogens to carcinogens.

2B. Alcohol interactions with oncogenes and tumor suppressor pathways

In addition to the mutagenic potential of alcohol metabolism, alcohol and its metabolites can alter metabolic and signaling pathways. Alcohol has been shown to modify signal transduction at multiple sites, by interacting directly with cell membranes as well as with signaling proteins and ion channels. A few examples of known interactions of alcohol with oncogene pathways are presented here. Others, reported or yet undiscovered, are also of interest.

Oncogenic pathways can be involved in cancer initiation, promotion, or progression and are possible targets of alcohol or its metabolites. For example, activating mutations of the Ras oncogene occur in many cancers, and activating mutations of K-ras have been detected following alcohol exposure. The activating K-ras mutation in esophageal squamous cell carcinoma correlates strongly with alcohol exposure. Ras operates through the MAPK pathway which regulates growth in response to extracellular factors.

The retinoblastoma (Rb) and p16^INK4A genes regulate cell cycle entry and are considered tumor suppressor genes. Impaired p16INK4A protein expression is associated with alcohol consumption in head and neck carcinoma. Further, the duration of exposure to alcohol predicts the homozygous deletion of p16^INK4A in esophageal cancers in long-term alcohol consumers. Commonly, hepatocellular carcinoma associated with excessive alcohol consumption displays at least one alteration in the Rb pathway, including p16^INK4A, p15^INK4B promoter methylation, RB1 alteration, or cyclinD1 amplification.

In addition, hepatocellular carcinomas also commonly display mutations in the p53 gene. P53 is a tumor suppressor that mediates DNA damage response and cell survival pathways. In nearly half of the hepatocellular carcinomas linked to alcohol consumption, mutations in both the Rb and p53 pathways occur. Mutations of p53 correlating with alcohol consumption also occur in head and neck squamous cell carcinoma.

2C. Alcohol interaction with other signal transduction pathways

Other signal transduction pathways involved in metabolic or developmental processes or exerting regulatory control are altered in the presence of alcohol. Modification of many of these same pathways is associated with carcinogenesis. A single example is presented.

The constitutive activation of the hedgehog (Hh) pathway in some cancers may promote cell growth and survival and maintain cancer stem cells. A potential role for Hh in the development of alcohol-associated hepatocellular carcinoma is supported by the following observations. Hh pathway activation has been observed in both mouse and human alcoholic liver disease and there is evidence for disruption of the Hh pathway at several stages of alcoholic liver disease. Hh signaling mediates the transition of hepatic stellate cells to the myofibroblast phenotype prior to cirrhosis, due to the fact that Hh regulates the epithelial to mesenchymal transition. Whether alcohol modification of the epithelial to mesenchymal transition leads directly to hepatocellular carcinogenesis is not yet clear. In addition, in some hepatocellular carcinomas, Hh promotes viability and protects from apoptosis.

2D. Mechanisms of alcohol-induced alterations of gene transcription

Many environmental factors for disease, including alcohol exposure, are known to cause epigenetic and transcriptional alterations. Alcohol is known to modulate DNA methylation, histone modifications, RNA-mediated gene silencing, and retinoic acid mediated transcription.

DNA methylation

Alcohol affects DNA methylation in at least two ways; first, by its interference with one carbon metabolism, and second, by alteration of the methylation of specific promoters. Chronic alcohol consumption is associated with poor folate absorption, reduction in methionine and S-adenosylmethionine availability and a general disruption of one-carbon metabolism. Folate deficiency by itself is linked to the damage of several specific oncogenes or signaling pathways important for tumorigenesis, and has been implicated in multiple cancer types. Multiple enzymes involved in the methionine cycle are inhibited by alcohol, ultimately disrupting the substrate availability for DNA methylation reactions. The effect of chronic alcohol ingestion on DNA methylation is complex, linked to greater methylation by some measures and demethylation of specific genes in other cases.

Histone modifications

Epigenetic modifications that involve histones include methylation, phosphorylation, acetylation, or ubiquitination. Each of these covalent modifications occurs on specific amino acids located in histone tails, with specific consequences for gene expression. Alcohol increases histone acetylation at H3K9 sites, which alters the state of chromatin in a tissue-specific manner, allowing access of the gene transcription machinery to the DNA. Another mechanism by which alcohol modifies acetylation involves the alteration of the NAD⁺: NADH⁺ ratio due to oxidative alcohol metabolism. Since SIRT histone deacetylases are NAD⁺-dependent, the altered NAD⁺ reduces the deacetylase activity of SIRT enzymes, potentially preventing the down-regulation of cancer-related genes. By these methods, alcohol may affect processes or signaling pathways that contribute to tumorigenesis.

MicroRNAs

Micro RNAs (miRNAs) are non-protein coding RNAs that influence cell cycle regulation, differentiation, immune cell development and organogenesis. Most cancer-related signaling pathways are under regulation by miRNAs, and altered miRNA expression is linked to a broad assortment of cancers. miRNA modulation has been shown to mediate some alcohol-induced disorders. For example, alcohol-associated alterations of the levels of specific miRNAs have been shown to moderate tolerance to alcohol, gut leakiness and neural stem cell proliferation. Thus, alcohol modulation of miRNA activity is a potential mechanism for alcohol-induced carcinogenesis.

Several reports of miRNA expression profiles in hepatocellular carcinoma identify significant increases or decreases in the expression of a small number of miRNAs that constitute miRNA signatures. In one case, the miRNA signature distinguishes between HCC (increase in miR-21, 10b, 222) and non-HCC (decrease in miR 200c) containing livers. A separate signature differentiates alcohol-associated HCC (decrease in miR-126) from hepatitis B virus-associated HCC (increase in miR-96). In addition to providing mechanistic insights into whether alcohol-induced miRNA changes mediate cancer initiation and progression, these signatures may be useful as diagnostic biomarkers or as therapeutic targets.

Retinoic acid

Retinoic acid (RA) exerts widespread, if not global, effects on gene transcription, through its activation of a family of nuclear RA-specific receptors that form heterodimers, each activating unique expression profiles. RA receptors thus regulate broad and diverse phenotypic effects, ranging from proliferation to differentiation. Alcohol metabolism can compete with retinoid metabolism in complex and tissue-specific ways, altering RA availability, and potentially disrupting cell fate decisions. Significantly, RA signaling is disrupted in most of the alcohol-associated cancers. In addition, altered retinoid metabolism causes changes in lipid metabolism and inflammation, two other processes that are the subject of investigation in mechanisms of tumorigenesis.

3. Local and systemic factors affecting tumor formation and maintenance

The tumor microenvironment plays a significant role in tumor survival. Tumors are populated by a diversity of tumor cells and stromal cells, including fibroblasts, leukocytes, lymphocytes, and vascular endothelial cells. The interaction between the tumor and its stroma plays an important part in tumor development and maintenance. Many components of the tumor niche can be influenced by alcohol. Since alcohol’s cancer-promoting properties are unique to certain organs, the tissue-specific factors that make the organs more susceptible to alcohol’s effects are of interest.

3A. Alcohol effects on stem cells and cancer stem cells

Alcohol’s effects on adult stem cells and cancer stem cells may explain the association of alcohol with the development of cancer in specific target organs. Each tissue is likely to have characteristic stem cells that repopulate the tissue during natural turnover. The unique characteristics of the healthy adult stem cells of each tissue, or the tissues unique niches, may dictate vulnerability to damage by alcohol. Alternatively, if alcohol impacts promotion or progression rather than initiation, then the cancer stem cell, bearing one or more oncogenic mutations, may be more sensitive to alcohol s possible disruption of signaling or cell cycle controls. Possible effects of ethanol on self renewal and differentiation are of interest.

3B. Alcohol and inflammation in cancer development

Clinical and molecular genetic evidence support a role for chronic inflammation in tumor initiation and progression. For example, chronic infection and autoimmune disease, two conditions characterized by chronic inflammation, are associated with cancers of various organs. In addition, polymorphisms in inflammatory mediator genes are associated with increased risk of lung and liver cancer. Chronic alcohol consumption is associated with chronic inflammation due to leakage of bacteria and bacterial products, predominantly lipopolysaccharide (LPS), from the gut into the liver and the bloodstream. LPS triggers innate immune cells to release pro-inflammatory cytokines and ROS to damage host tissue and possibly initiate tumors.

Alcoholic liver disease, a frequent complication for chronic alcoholics, is a strong predictor for hepatocellular carcinoma. Inflammatory conditions resulting from LPS leakage support the progression of liver disease. In fact, chronic inflammation is a central component of both alcohol-associated as well as hepatitis B and C virus-related hepatocellular carcinoma. Further, alcohol consumption in combination with HCV infection exacerbates the progression to hepatocellular carcinoma.

In non-malignant alcoholic liver disease, fibrosis results from the subversion of normal repair processes; a similar aberration may contribute to compensatory proliferation, hyperplasia and malignancy in other organs. The epithelial to mesenchymal transition plays a role in alcoholic liver disease and fibrosis. The potential effect of alcohol on the epithelial to mesenchymal transition in other niches remains to be determined.

3C. Alcohol and immune surveillance

Alcohol consumption has profound effects on innate and adaptive immunity, suggesting that alcohol has the potential to disrupt immune surveillance at multiple sites. The tumor microenvironment is enriched with immune cells, and the composition of the immune cell infiltrate has clinical relevance. The presence of cytotoxic CD8+ T cells and markers of Th1 polarization in human colorectal cancer have a favorable prognosis for the patient, while Treg infiltrates predominate in late stage tumors and confer a negative prognosis. Direct evidence for alteration of anti-tumor immunity by alcohol exposure in a mouse model supports the need for further investigation in the area.

3D. Alcohol and angiogenesis

As tumors grow, tumor volume precludes oxygen diffusion to the center of the tumor, so vascularization of tumors is essential to survival and further growth. Vascular endothelial growth factor (VEGF), which mediates the process of vascularization, is up-regulated by alcohol exposure in a mouse model, and VEGF expression correlates with increased tumor volume. Thus, alcohol may support the progression of established tumors in humans by supporting angiogenesis.

3E. Potential hormonal effects on alcohol-induced cancers

Alcohol-associated cancers of the upper aerodigestive tract, liver and colon occur at higher levels in men than in women. Since men drink more alcohol, smoke more often and are more likely to be infected by HBV or HCV than women, the simplest explanation for the greater cancer incidence in men may be a greater exposure to the risk factors. However, biological and endocrine differences may also account for the differences in prevalence of these cancers in men and women.

Also of interest are possible interactions between alcohol and estrogens in the development of breast cancer. Both estrogen availability and intracellular estrogen signaling are potential targets for alcohol effects. Circulating estrogen levels are altered by alcohol consumption in both pre-menopausal and post-menopausal women, potentially fueling hormone-dependent tumors. At the cellular level, epidemiological and experimental evidence implicate estrogen signaling in alcohol-associated cancers of the breast. Alcohol’s potential to modulate estrogen signaling at multiple points, including at the ligand, receptor and transcriptional levels, warrants further investigation and may provide potential avenues of therapeutic intervention.

Significance

Two thirds of adults in the United States consume alcohol at some level. Current guidelines for moderate drinking address alcohol intake that is beneficial to cardiac health, but even a moderate level of consumption may increase the risk of other diseases, specifically breast cancer. Educating the public about the relative risks and benefits of alcohol consumption requires sound scientific evidence. In addition to alcohol as a single risk factor, it also interacts synergistically with other risk factors, including viral hepatitis B and C, smoking and obesity to increase cancer incidence. Expanding insights into these cancer mechanisms, separately and in combination, will not only provide a basis on which the general public can make rational decisions about their alcohol consumption, it will also be useful for developing preventative or protective strategies by providing molecular targets for therapeutic approaches. In particular, clarification of the molecular processes affected by alcohol leading to cancer in breast tissue could provide the basis for women’s informed choices on frequency and volume of alcohol consumption.

Areas of Research Interest

The focus of this FOA is to encourage investigation into the mechanism(s) by which alcohol contributes to the development, initiation, promotion, progression or metastasis of cancer. As alcohol’s cancer-inducing properties are unique to certain organs, the tissue-specific factors that make each organ more susceptible to alcohol’s effects are of interest. Investigators are encouraged to employ models of cancers that have been convincingly linked to alcohol consumption in humans, including cancers of the oral cavity and pharynx, esophagus, larynx, liver, breast, and colon. This FOA encourages research activities into the molecular, cellular, hormonal, immunological, and physiological factors that contribute to alcohol-induced cancer. Research topics of interest include, but are not limited to:

• Elucidate the cellular and molecular mechanisms underlying the carcinogenic effects of alcohol or its metabolites, with particular emphasis on tissue specific conditions;
• Explore associations between polymorphisms involved in alcohol metabolism and increased susceptibility to carcinogenesis, especially at the tissue specific level;
• Examine alcohol’s effects on signaling pathways involved in cell proliferation, survival, cell death, angiogenesis, and metastasis;
• Investigate the microenvironment in the organs which support alcohol-related cancers, with elucidation of the characteristics that make them more susceptible to alcohol modifications that lead to initiation and establishment of cancer;
• Investigate thyroid-specific alcohol metabolism or other niche characteristics that contribute to the decreased incidence of thyroid cancer with moderate alcohol consumption;
• Assess the role of CYP2E1 and other cytochrome P450 enzymes in alcohol related carcinogenesis, including ROS generation, alteration in retinoid metabolism, and the activation of procarcinogens to carcinogens;
• Identify alcohol-induced epigenetic changes during initiation and progression of tumorigenesis, using genome-wide approach or candidate gene approaches;
• Explore epigenetic changes as biomarkers or therapeutic targets for alcohol-related cancers;
• Elucidate the molecular mechanisms underlying gene-alcohol-diet interactions that influence risk for cancer (i.e., polymorphisms in one carbon metabolism enzymes-alcohol-folate);
• Identify and validate genomic, proteomic, metabolomic, lipidomic or other omic signatures that constitute reliable biomarkers of alcohol-associated cancers;
• Investigate organ-specific and systemic effects of alcohol on retinoic acid homeostasis;
• Assess the impact of alcohol on retinoic acid cross-talk with cellular signal transduction pathways and transcription factors that regulate lipid metabolism, inflammation, and tissue remodeling;
• Investigate in animal models the role of nutrition-alcohol interactions in the fetal origins of cancer;
• Characterize the complex relationships between alcohol-induced cancers, intracellular stress responses and proteostasis;
• Investigate the significance of energy homeostasis, including, but not limited to, obesity and diabetes, in the initiation and progression of alcohol-related cancers;
• Examine alcohol’s effects on immune suppression and tumor escape in cancers associated with chronic alcohol consumption;
• Investigate the interactions between alcohol and hepatitis viruses in the etiology and progression of hepatocellular carcinoma;
• Assess the possible contribution of the microbiome to the pro-tumorigenic role of alcohol-related inflammation on carcinogenesis;
• Characterize the effects of alcohol on endogenous adult stem cells or progenitor cells, their role in self-renewal and differentiation, their potential role in tumorigenesis, and their interaction with other factors such as nutrition and viral infection;
• Define the effects of alcohol on cancer stem cells;
• Investigate the effects of alcohol on metastasis including, but not limited to, alterations in signaling pathways, matrix metalloprotease function, cell adhesion processes, or factors that affect tumor cell motility and seeding at secondary sites.

Additional Research Interests of NCI:

Tobacco and alcohol are frequently used together. The International Agency for Research on Cancer has concluded there are over 70 carcinogens in tobacco smoke for which we have sufficient evidence for carcinogenicity in either laboratory animals or humans. At least 28 carcinogens have been identified in non-smoked oral tobacco products, including tobacco-specific nitrosamines, which have been found to cause tumors in animal models and are associated with mechanisms of carcinogenesis in humans. Carcinogenic chemicals, including formaldehyde, acetaldehyde and other carbonyl compounds, as well as heavy metals and tobacco specific nitrosamines, have also been found in the aerosol of Electronic Nicotine Delivery Systems (ENDS), including electronic cigarettes. Cigarette smokers, and users of other combusted products, have a greater likelihood of alcohol use than nonsmokers, and alcohol users are more likely to smoke than non-drinkers. Epidemiologic evidence demonstrates that users of both tobacco and alcohol greatly increases the risk of developing cancers of the oral cavity, pharynx, larynx, and esophagus. However, no single mechanism clearly explains these observations. Alcohol could act as a solvent, increasing absorption of tobacco-specific carcinogens. In the body, ethanol in alcoholic beverages is converted to the carcinogen acetaldehyde. In addition, studies have demonstrated that alcohol may inhibit hepatic metabolism, which could impact clearance of carcinogens found in tobacco smoke. Research seeking to elucidate the mechanisms by which components of tobacco products, including ENDS interact with alcohol consumption to affect carcinogenesis is of high interest.

• Elucidating the potential combined effects of concurrent use of alcohol and tobacco products, including electronic nicotine delivery systems (ENDS), on cancer biology
• Investigations using animal models to determine the role of prenatal exposure to tobacco products and alcohol on cancer development and risk.
• Understanding how the microbiome affects alcohol- and tobacco-mediated carcinogenesis.
• Characterizing the role of alcohol and tobacco products, including ENDS aerosol components or mixtures, on inflammation as it relates to tumorigenesis.

This FOA is intended to attract applications that use comprehensive approaches to address mechanistic questions about alcohol s effect on cancer development. Genomic, proteomic, metabolomic, lipidomic techniques and systems biology approaches are welcome. Collaborations using existing surveys, repositories and genomics databases to clarify alcohol contributions to cancer development are encouraged. Study designs exploiting established preclinical cancer models for studying alcohol-related carcinogenesis are also encouraged.

See Section VIII. Other Information for award authorities and regulations.

NIH grants policies as described in the NIH Grants Policy Statement will apply to the applications submitted and awards made in response to this FOA.

Higher Education Institutions

• Public/State Controlled Institutions of Higher Education
• Private Institutions of Higher Education

The following types of Higher Education Institutions are always encouraged to apply for NIH support as Public or Private Institutions of Higher Education:

• Hispanic-serving Institutions
• Historically Black Colleges and Universities (HBCUs)
• Tribally Controlled Colleges and Universities (TCCUs)
• Alaska Native and Native Hawaiian Serving Institutions
• Asian American Native American Pacific Islander Serving Institutions (AANAPISIs)

Nonprofits Other Than Institutions of Higher Education

• Nonprofits with 501(c)(3) IRS Status (Other than Institutions of Higher Education)
• Nonprofits without 501(c)(3) IRS Status (Other than Institutions of Higher Education)

For-Profit Organizations

• Small Businesses
• For-Profit Organizations (Other than Small Businesses)

Governments

• State Governments
• County Governments
• City or Township Governments
• Special District Governments
• Indian/Native American Tribal Governments (Federally Recognized)
• Indian/Native American Tribal Governments (Other than Federally Recognized)
• Eligible Agencies of the Federal Government
• U.S. Territory or Possession

Other

• Independent School Districts
• Public Housing Authorities/Indian Housing Authorities
• Native American Tribal Organizations (other than Federally recognized tribal governments)
• Faith-based or Community-based Organizations
• Regional Organizations
• Non-domestic (non-U.S.) Entities (Foreign Institutions)

Non-domestic (non-U.S.) Entities (Foreign Institutions) are eligible to apply.
Non-domestic (non-U.S.) components of U.S. Organizations are eligible to apply.
Foreign components, as defined in the NIH Grants Policy Statement, are allowed.

Applicant Organizations

Applicant organizations must complete and maintain the following registrations as described in the SF 424 (R&R) Application Guide to be eligible to apply for or receive an award. All registrations must be completed prior to the application being submitted. Registration can take 6 weeks or more, so applicants should begin the registration process as soon as possible. The NIH Policy on Late Submission of Grant Applications states that failure to complete registrations in advance of a due date is not a valid reason for a late submission.

• Dun and Bradstreet Universal Numbering System (DUNS) - All registrations require that applicants be issued a DUNS number. After obtaining a DUNS number, applicants can begin both SAM and eRA Commons registrations. The same DUNS number must be used for all registrations, as well as on the grant application.
• System for Award Management (SAM) (formerly CCR) Applicants must complete and maintain an active registration, which requires renewal at least annually. The renewal process may require as much time as the initial registration. SAM registration includes the assignment of a Commercial and Government Entity (CAGE) Code for domestic organizations which have not already been assigned a CAGE Code.
• NATO Commercial and Government Entity (NCAGE) Code Foreign organizations must obtain an NCAGE code (in lieu of a CAGE code) in order to register in SAM.
• eRA Commons - Applicants must have an active DUNS number and SAM registration in order to complete the eRA Commons registration. Organizations can register with the eRA Commons as they are working through their SAM or Grants.gov registration. eRA Commons requires organizations to identify at least one Signing Official (SO) and at least one Program Director/Principal Investigator (PD/PI) account in order to submit an application.
• Grants.gov Applicants must have an active DUNS number and SAM registration in order to complete the Grants.gov registration.

Program Directors/Principal Investigators (PD(s)/PI(s))

All PD(s)/PI(s) must have an eRA Commons account. PD(s)/PI(s) should work with their organizational officials to either create a new account or to affiliate their existing account with the applicant organization in eRA Commons. If the PD/PI is also the organizational Signing Official, they must have two distinct eRA Commons accounts, one for each role. Obtaining an eRA Commons account can take up to 2 weeks.

Any individual(s) with the skills, knowledge, and resources necessary to carry out the proposed research as the Program Director(s)/Principal Investigator(s) (PD(s)/PI(s)) is invited to work with his/her organization to develop an application for support. Individuals from underrepresented racial and ethnic groups as well as individuals with disabilities are always encouraged to apply for NIH support.

For institutions/organizations proposing multiple PDs/PIs, visit the Multiple Program Director/Principal Investigator Policy and submission details in the Senior/Key Person Profile (Expanded) Component of the SF424 (R&R) Application Guide.

This FOA does not require cost sharing as defined in the NIH Grants Policy Statement.

Applicant organizations may submit more than one application, provided that each application is scientifically distinct.

The NIH will not accept duplicate or highly overlapping applications under review at the same time. This means that the NIH will not accept:

• A new (A0) application that is submitted before issuance of the summary statement from the review of an overlapping new (A0) or resubmission (A1) application.
• A resubmission (A1) application that is submitted before issuance of the summary statement from the review of the previous new (A0) application.
• An application that has substantial overlap with another application pending appeal of initial peer review (see NOT-OD-11-101).

Buttons to access the online ASSIST system or to download application forms are available in Part 1 of this FOA. See your administrative office for instructions if you plan to use an institutional system-to-system solution.

It is critical that applicants follow the Research (R) Instructions in the SF424 (R&R) Application Guide, including Supplemental Grant Application Instructions except where instructed in this funding opportunity announcement to do otherwise. Conformance to the requirements in the Application Guide is required and strictly enforced. Applications that are out of compliance with these instructions may be delayed or not accepted for review.

For information on Application Submission and Receipt, visit Frequently Asked Questions Application Guide, Electronic Submission of Grant Applications.

All page limitations described in the SF424 Application Guide and the Table of Page Limits must be followed.

The following section supplements the instructions found in the SF424 (R&R) Application Guide and should be used for preparing an application to this FOA.

All instructions in the SF424 (R&R) Application Guide must be followed.

All instructions in the SF424 (R&R) Application Guide must be followed.

All instructions in the SF424 (R&R) Application Guide must be followed.

All instructions in the SF424 (R&R) Application Guide must be followed.

All instructions in the SF424 (R&R) Application Guide must be followed.

All instructions in the SF424 (R&R) Application Guide must be followed.

All instructions in the SF424 (R&R) Application Guide must be followed.

All instructions in the SF424 (R&R) Application Guide must be followed, with the following additional instructions:

Resource Sharing Plan: Individuals are required to comply with the instructions for the Resource Sharing Plans as provided in the SF424 (R&R) Application Guide.

Appendix:

Do not use the Appendix to circumvent page limits. Follow all instructions for the Appendix as described in the SF424 (R&R) Application Guide.

When conducting clinical research, follow all instructions for completing PHS Inclusion Enrollment Report as described in the SF424 (R&R) Application Guide.

Form only available in FORMS-E application packages for use with due dates on or after January 25, 2018.

When involving NIH-defined human subjects research, clinical research, and/or clinical trials follow all instructions for the PHS Human Subjects and Clinical Trials Information form in the SF424 (R&R) Application Guide, with the following additional instructions:

If you answered "Yes" to the question "Are Human Subjects Involved?" on the R&R Other Project Information form, you must include at least one human subjects study record using the Study Record: PHS Human Subjects and Clinical Trials Information form or a Delayed Onset Study record.

Study Record: PHS Human Subjects and Clinical Trials Information
All instructions in the SF424 (R&R) Application Guide must be followed.

Delayed Onset Study: All instructions in the SF424 (R&R) Application Guide must be followed.

All instructions in the SF424 (R&R) Application Guide must be followed.

Foreign (non-U.S.) institutions must follow policies described in the NIH Grants Policy Statement, and procedures for foreign institutions described throughout the SF424 (R&R) Application Guide.

See Part 1. Section III.1 for information regarding the requirement for obtaining a unique entity identifier and for completing and maintaining active registrations in System for Award Management (SAM), NATO Commercial and Government Entity (NCAGE) Code (if applicable), eRA Commons, and Grants.gov

Part I. Overview Information contains information about Key Dates and times. Applicants are encouraged to submit applications before the due date to ensure they have time to make any application corrections that might be necessary for successful submission. When a submission date falls on a weekend or Federal holiday, the application deadline is automatically extended to the next business day.

Organizations must submit applications to Grants.gov (the online portal to find and apply for grants across all Federal agencies). Applicants must then complete the submission process by tracking the status of the application in the eRA Commons, NIH’s electronic system for grants administration. NIH and Grants.gov systems check the application against many of the application instructions upon submission. Errors must be corrected and a changed/corrected application must be submitted to Grants.gov on or before the application due date and time. If a Changed/Corrected application is submitted after the deadline, the application will be considered late. Applications that miss the due date and time are subjected to the NIH Policy on Late Application Submission.

Applicants are responsible for viewing their application before the due date in the eRA Commons to ensure accurate and successful submission.

Information on the submission process and a definition of on-time submission are provided in the SF424 (R&R) Application Guide.

This initiative is not subject to intergovernmental review.

All NIH awards are subject to the terms and conditions, cost principles, and other considerations described in the NIH Grants Policy Statement.

Pre-award costs are allowable only as described in the NIH Grants Policy Statement.

Applications must be submitted electronically following the instructions described in the SF424 (R&R) Application Guide. Paper applications will not be accepted.

Applicants must complete all required registrations before the application due date. Section III. Eligibility Information contains information about registration.

For assistance with your electronic application or for more information on the electronic submission process, visit Applying Electronically. If you encounter a system issue beyond your control that threatens your ability to complete the submission process on-time, you must follow the Guidelines for Applicants Experiencing System Issues. For assistance with application submission, contact the Application Submission Contacts in Section VII.

Important reminders:

All PD(s)/PI(s) must include their eRA Commons ID in the Credential field of the Senior/Key Person Profile Component of the SF424(R&R) Application Package. Failure to register in the Commons and to include a valid PD/PI Commons ID in the credential field will prevent the successful submission of an electronic application to NIH. See Section III of this FOA for information on registration requirements.

The applicant organization must ensure that the DUNS number it provides on the application is the same number used in the organization’s profile in the eRA Commons and for the System for Award Management. Additional information may be found in the SF424 (R&R) Application Guide.

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Upon receipt, applications will be evaluated for completeness and compliance with application instructions by the Center for Scientific Review, NIH. Applications that are incomplete or non-compliant will not be reviewed.

Applicants requesting $500,000 or more in direct costs in any year (excluding consortium F&A) must contact a Scientific/ Research Contact at least 6 weeks before submitting the application and follow the Policy on the Acceptance for Review of Unsolicited Applications that Request $500,000 or More in Direct Costs as described in the SF424 (R&R) Application Guide.

Applicants are required to follow the instructions for post-submission materials, as described in the policy.

Important Update: See NOT-OD-18-228 for updated review language for due dates on or after January 25, 2019.

Only the review criteria described below will be considered in the review process. As part of the NIH mission, all applications submitted to the NIH in support of biomedical and behavioral research are evaluated for scientific and technical merit through the NIH peer review system.

Reviewers will provide an overall impact score to reflect their assessment of the likelihood for the project to exert a sustained, powerful influence on the research field(s) involved, in consideration of the following review criteria and additional review criteria (as applicable for the project proposed).

Reviewers will consider each of the review criteria below in the determination of scientific merit, and give a separate score for each. An application does not need to be strong in all categories to be judged likely to have major scientific impact. For example, a project that by its nature is not innovative may be essential to advance a field.

Does the project address an important problem or a critical barrier to progress in the field? Is there a strong scientific premise for the project? If the aims of the project are achieved, how will scientific knowledge, technical capability, and/or clinical practice be improved? How will successful completion of the aims change the concepts, methods, technologies, treatments, services, or preventative interventions that drive this field?

Are the PD(s)/PI(s), collaborators, and other researchers well suited to the project? If Early Stage Investigators or those in the early stages of independent careers, do they have appropriate experience and training? If established, have they demonstrated an ongoing record of accomplishments that have advanced their field(s)? If the project is collaborative or multi-PD/PI, do the investigators have complementary and integrated expertise; are their leadership approach, governance and organizational structure appropriate for the project?

Does the application challenge and seek to shift current research or clinical practice paradigms by utilizing novel theoretical concepts, approaches or methodologies, instrumentation, or interventions? Are the concepts, approaches or methodologies, instrumentation, or interventions novel to one field of research or novel in a broad sense? Is a refinement, improvement, or new application of theoretical concepts, approaches or methodologies, instrumentation, or interventions proposed?

Are the overall strategy, methodology, and analyses well-reasoned and appropriate to accomplish the specific aims of the project? Have the investigators presented strategies to ensure a robust and unbiased approach, as appropriate for the work proposed? Are potential problems, alternative strategies, and benchmarks for success presented? If the project is in the early stages of development, will the strategy establish feasibility and will particularly risky aspects be managed? Have the investigators presented adequate plans to address relevant biological variables, such as sex, for studies in vertebrate animals or human subjects?

If the project involves human subjects and/or NIH-defined clinical research, are the plans to address 1) the protection of human subjects from research risks, and 2) inclusion (or exclusion) of individuals on the basis of sex/gender, race, and ethnicity, as well as the inclusion or exclusion of children, justified in terms of the scientific goals and research strategy proposed?

Will the scientific environment in which the work will be done contribute to the probability of success? Are the institutional support, equipment and other physical resources available to the investigators adequate for the project proposed? Will the project benefit from unique features of the scientific environment, subject populations, or collaborative arrangements?

As applicable for the project proposed, reviewers will evaluate the following additional items while determining scientific and technical merit, and in providing an overall impact score, but will not give separate scores for these items.

For research that involves human subjects but does not involve one of the six categories of research that are exempt under 45 CFR Part 46, the committee will evaluate the justification for involvement of human subjects and the proposed protections from research risk relating to their participation according to the following five review criteria: 1) risk to subjects, 2) adequacy of protection against risks, 3) potential benefits to the subjects and others, 4) importance of the knowledge to be gained, and 5) data and safety monitoring for clinical trials.

For research that involves human subjects and meets the criteria for one or more of the six categories of research that are exempt under 45 CFR Part 46, the committee will evaluate: 1) the justification for the exemption, 2) human subjects involvement and characteristics, and 3) sources of materials. For additional information on review of the Human Subjects section, please refer to the Guidelines for the Review of Human Subjects.

When the proposed project involves human subjects and/or NIH-defined clinical research, the committee will evaluate the proposed plans for the inclusion (or exclusion) of individuals on the basis of sex/gender, race, and ethnicity, as well as the inclusion (or exclusion) of children to determine if it is justified in terms of the scientific goals and research strategy proposed. For additional information on review of the Inclusion section, please refer to the Guidelines for the Review of Inclusion in Clinical Research.

The committee will evaluate the involvement of live vertebrate animals as part of the scientific assessment according to the following criteria: (1) description of proposed procedures involving animals, including species, strains, ages, sex, and total number to be used; (2) justifications for the use of animals versus alternative models and for the appropriateness of the species proposed; (3) interventions to minimize discomfort, distress, pain and injury; and (4) justification for euthanasia method if NOT consistent with the AVMA Guidelines for the Euthanasia of Animals. Reviewers will assess the use of chimpanzees as they would any other application proposing the use of vertebrate animals. For additional information on review of the Vertebrate Animals section, please refer to the Worksheet for Review of the Vertebrate Animal Section.

Reviewers will assess whether materials or procedures proposed are potentially hazardous to research personnel and/or the environment, and if needed, determine whether adequate protection is proposed.

For Resubmissions, the committee will evaluate the application as now presented, taking into consideration the responses to comments from the previous scientific review group and changes made to the project.

For Renewals, the committee will consider the progress made in the last funding period.

For Revisions, the committee will consider the appropriateness of the proposed expansion of the scope of the project. If the Revision application relates to a specific line of investigation presented in the original application that was not recommended for approval by the committee, then the committee will consider whether the responses to comments from the previous scientific review group are adequate and whether substantial changes are clearly evident.

As applicable for the project proposed, reviewers will consider each of the following items, but will not give scores for these items, and should not consider them in providing an overall impact score.

Reviewers will assess whether the project presents special opportunities for furthering research programs through the use of unusual talent, resources, populations, or environmental conditions that exist in other countries and either are not readily available in the United States or augment existing U.S. resources.

Reviewers will assess the information provided in this section of the application, including 1) the Select Agent(s) to be used in the proposed research, 2) the registration status of all entities where Select Agent(s) will be used, 3) the procedures that will be used to monitor possession use and transfer of Select Agent(s), and 4) plans for appropriate biosafety, biocontainment, and security of the Select Agent(s).

Reviewers will comment on whether the following Resource Sharing Plans, or the rationale for not sharing the following types of resources, are reasonable: (1) Data Sharing Plan; (2) Sharing Model Organisms; and (3) Genomic Data Sharing Plan (GDS).

For projects involving key biological and/or chemical resources, reviewers will comment on the brief plans proposed for identifying and ensuring the validity of those resources.

Reviewers will consider whether the budget and the requested period of support are fully justified and reasonable in relation to the proposed research.

Applications will be evaluated for scientific and technical merit by (an) appropriate Scientific Review Group(s) convened by the Center for Scientific Review, in accordance with NIH peer review policy and procedures, using the stated review criteria. Assignment to a Scientific Review Group will be shown in the eRA Commons.

As part of the scientific peer review, all applications:

• May undergo a selection process in which only those applications deemed to have the highest scientific and technical merit (generally the top half of applications under review) will be discussed and assigned an overall impact score.
• Will receive a written critique.

Applications will be assigned on the basis of established PHS referral guidelines to the appropriate NIH Institute or Center. Applications will compete for available funds with all other recommended applications. Following initial peer review, recommended applications will receive a second level of review by the appropriate national Advisory Council or Board. The following will be considered in making funding decisions:

• Scientific and technical merit of the proposed project as determined by scientific peer review.
• Availability of funds.
• Relevance of the proposed project to program priorities.

After the peer review of the application is completed, the PD/PI will be able to access his or her Summary Statement (written critique) via the eRA Commons. Refer to Part 1 for dates for peer review, advisory council review, and earliest start date.

Information regarding the disposition of applications is available in the NIH Grants Policy Statement.

If the application is under consideration for funding, NIH will request "just-in-time" information from the applicant as described in the NIH Grants Policy Statement.

A formal notification in the form of a Notice of Award (NoA) will be provided to the applicant organization for successful applications. The NoA signed by the grants management officer is the authorizing document and will be sent via email to the grantee’s business official.

Awardees must comply with any funding restrictions described in Section IV.5. Funding Restrictions. Selection of an application for award is not an authorization to begin performance. Any costs incurred before receipt of the NoA are at the recipient's risk. These costs may be reimbursed only to the extent considered allowable pre-award costs.

Any application awarded in response to this FOA will be subject to terms and conditions found on the Award Conditions and Information for NIH Grants website. This includes any recent legislation and policy applicable to awards that is highlighted on this website.

All NIH grant and cooperative agreement awards include the NIH Grants Policy Statement as part of the NoA. For these terms of award, see the NIH Grants Policy Statement Part II: Terms and Conditions of NIH Grant Awards, Subpart A: General and Part II: Terms and Conditions of NIH Grant Awards, Subpart B: Terms and Conditions for Specific Types of Grants, Grantees, and Activities. More information is provided at Award Conditions and Information for NIH Grants.

Recipients of federal financial assistance (FFA) from HHS must administer their programs in compliance with federal civil rights law. This means that recipients of HHS funds must ensure equal access to their programs without regard to a person’s race, color, national origin, disability, age and, in some circumstances, sex and religion. This includes ensuring your programs are accessible to persons with limited English proficiency. HHS recognizes that research projects are often limited in scope for many reasons that are nondiscriminatory, such as the principal investigator’s scientific interest, funding limitations, recruitment requirements, and other considerations. Thus, criteria in research protocols that target or exclude certain populations are warranted where nondiscriminatory justifications establish that such criteria are appropriate with respect to the health or safety of the subjects, the scientific study design, or the purpose of the research.

For additional guidance regarding how the provisions apply to NIH grant programs, please contact the Scientific/Research Contact that is identified in Section VII under Agency Contacts of this FOA. HHS provides general guidance to recipients of FFA on meeting their legal obligation to take reasonable steps to provide meaningful access to their programs by persons with limited English proficiency. Please see https://www.hhs.gov/civil-rights/for-individuals/special-topics/limited-english-proficiency/index.html. The HHS Office for Civil Rights also provides guidance on complying with civil rights laws enforced by HHS. Please see http://www.hhs.gov/ocr/civilrights/understanding/section1557/index.html; and https://www.hhs.gov/civil-rights/for-providers/laws-regulations-guidance/index.html. Recipients of FFA also have specific legal obligations for serving qualified individuals with disabilities. Please see http://www.hhs.gov/ocr/civilrights/understanding/disability/index.html. Please contact the HHS Office for Civil Rights for more information about obligations and prohibitions under federal civil rights laws at https://www.hhs.gov/ocr/about-us/contact-us/index.html or call 1-800-368-1019 or TDD 1-800-537-7697. Also note it is an HHS Departmental goal to ensure access to quality, culturally competent care, including long-term services and supports, for vulnerable populations. For further guidance on providing culturally and linguistically appropriate services, recipients should review the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care at http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53.

In accordance with the statutory provisions contained in Section 872 of the Duncan Hunter National Defense Authorization Act of Fiscal Year 2009 (Public Law 110-417), NIH awards will be subject to the Federal Awardee Performance and Integrity Information System (FAPIIS) requirements. FAPIIS requires Federal award making officials to review and consider information about an applicant in the designated integrity and performance system (currently FAPIIS) prior to making an award. An applicant, at its option, may review information in the designated integrity and performance systems accessible through FAPIIS and comment on any information about itself that a Federal agency previously entered and is currently in FAPIIS. The Federal awarding agency will consider any comments by the applicant, in addition to other information in FAPIIS, in making a judgement about the applicant’s integrity, business ethics, and record of performance under Federal awards when completing the review of risk posed by applicants as described in 45 CFR Part 75.205 Federal awarding agency review of risk posed by applicants. This provision will apply to all NIH grants and cooperative agreements except fellowships.

Cooperative Agreement Terms and Conditions of Award

Not Applicable

When multiple years are involved, awardees will be required to submit the Research Performance Progress Report (RPPR) annually and financial statements as required in the NIH Grants Policy Statement.

A final progress report, invention statement, and the expenditure data portion of the Federal Financial Report are required for closeout of an award, as described in the NIH Grants Policy Statement.

The Federal Funding Accountability and Transparency Act of 2006 (Transparency Act), includes a requirement for awardees of Federal grants to report information about first-tier subawards and executive compensation under Federal assistance awards issued in FY2011 or later. All awardees of applicable NIH grants and cooperative agreements are required to report to the Federal Subaward Reporting System (FSRS) available at www.fsrs.gov on all subawards over $25,000. See the NIH Grants Policy Statement for additional information on this reporting requirement.

In accordance with the regulatory requirements provided at 45 CFR 75.113 and Appendix XII to 45 CFR Part 75, recipients that have currently active Federal grants, cooperative agreements, and procurement contracts from all Federal awarding agencies with a cumulative total value greater than $10,000,000 for any period of time during the period of performance of a Federal award, must report and maintain the currency of information reported in the System for Award Management (SAM) about civil, criminal, and administrative proceedings in connection with the award or performance of a Federal award that reached final disposition within the most recent five-year period. The recipient must also make semiannual disclosures regarding such proceedings. Proceedings information will be made publicly available in the designated integrity and performance system (currently FAPIIS). This is a statutory requirement under section 872 of Public Law 110-417, as amended (41 U.S.C. 2313). As required by section 3010 of Public Law 111-212, all information posted in the designated integrity and performance system on or after April 15, 2011, except past performance reviews required for Federal procurement contracts, will be publicly available. Full reporting requirements and procedures are found in Appendix XII to 45 CFR Part 75 Award Term and Conditions for Recipient Integrity and Performance Matters.

We encourage inquiries concerning this funding opportunity and welcome the opportunity to answer questions from potential applicants.

eRA Service Desk (Questions regarding ASSIST, eRA Commons registration, submitting and tracking an application, documenting system problems that threaten submission by the due date, post submission issues)
Finding Help Online: http://grants.nih.gov/support/ (preferred method of contact)
Telephone: 301-402-7469 or 866-504-9552 (Toll Free)

Grants.gov Customer Support (Questions regarding Grants.gov registration and submission, downloading forms and application packages)
Contact Center Telephone: 800-518-4726
Email: support@grants.gov

GrantsInfo (Questions regarding application instructions and process, finding NIH grant resources)
Email: GrantsInfo@nih.gov (preferred method of contact)
Telephone: 301-945-7573

Bill Dunty, Ph.D.
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Telephone: 301-443-7351
Email: duntyw@mail.nih.gov

Gary Murray, Ph.D.
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Telephone: 301-443-9940
Email: murrayg@mail.nih.gov

Ron Johnson, Ph.D.
National Cancer Institute (NCI)
Telephone: 240-276-6250
Email: rjohnso2@mail.nih.gov

Examine your eRA Commons account for review assignment and contact information (information appears two weeks after the submission due date).

Judy Fox
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Telephone: 301-443-4704
Email: jfox@mail.nih.gov

Alice C. Wong, CRA
National Cancer Institute (NCI)
Telephone: 240-276-6299
Email: wongalice@mail.nih.gov

Recently issued trans-NIH policy notices may affect your application submission. A full list of policy notices published by NIH is provided in the NIH Guide for Grants and Contracts. All awards are subject to the terms and conditions, cost principles, and other considerations described in the NIH Grants Policy Statement.

Awards are made under the authorization of Sections 301 and 405 of the Public Health Service Act as amended (42 USC 241 and 284) and under Federal Regulations 42 CFR Part 52 and 45 CFR Part 75.