Human populations exhibit genetic polymorphism in N-acetylation capacity, catalyzed by N-acetyltransferase 2 (NAT2). We investigated the relationship between NAT2 acetylator genotype and phenotype in cryopreserved human hepatocytes. NAT2 genotypes determined in 256 human samples were assigned as rapid (two rapid alleles), intermediate (one rapid and one slow allele), or slow (two slow alleles) acetylator phenotypes based on functional characterization of the NAT2 alleles reported previously in recombinant expression systems. A robust and significant relationship was observed between deduced NAT2 phenotype (rapid, intermediate, or slow) and Nacetyltransferase activity toward sulfamethazine (p Ͻ 0.0001) and 4-aminobiphenyl (p Ͻ 0.0001) and for O-acetyltransferasecatalyzed metabolic activation of N-hydroxy-4-aminobiphenyl (p Ͻ 0.0001), N-hydroxy-2-amino-3,8-dimethylimidazo[4,5-f] quinoxaline (p Ͻ 0.01), and N-hydroxy-2-amino-1-methyl-6-phenylimidazo [4,5-b] pyridine (p Ͻ 0.0001). NAT2-specific protein levels also significantly associated with the rapid, intermediate, and slow NAT2 acetylator phenotypes (p Ͻ 0.0001). As a negative control, p-aminobenzoic acid (an N-acetyltransferase 1-selective substrate) N-acetyltransferase activities from the same samples did not correlate with the three NAT2 acetylator phenotypes (p Ͼ 0.05). These results clearly document codominant expression of human NAT2 alleles resulting in rapid, intermediate, and slow acetylator phenotypes. The three phenotypes reflect levels of NAT2 protein catalyzing both N-and O-acetylation. Our results suggest a significant role of NAT2 acetylation polymorphism in arylamine-induced cancers and are consistent with differential cancer risk and/or drug efficacy/ toxicity in intermediate compared with rapid or slow NAT2 acetylator phenotypes.The N-acetylation polymorphism was discovered more than 50 years ago when individual variability in isoniazid neurotoxicity was attributed to genetic variability in Nacetylation capacity identified as rapid and slow acetylators (Evans et al., 1960). In addition to isoniazid, many aromatic amine drugs such as sulfamethazine (SMZ) are subject to the acetylation polymorphism thus affecting therapeutic efficacy and toxicity for many therapeutic drugs (reviewed by Weber and Hein, 1985). Whereas the N-acetylation of isoniazid and SMZ divided human populations into rapid and slow acetylator phenotypes, the Nacetylation of drugs such as p-aminosalicylic acid yielded apparently unimodal distributions of individuals (reviewed in Weber and Hein, 1985). The biochemical basis relates to substrate specificity and molecular genetics of two distinct N-acetyltransferase isozymes, subsequently identified as Nacetyltransferase 1 (NAT1) and N-acetyltransferase 2 (NAT2) (reviewed by Grant, 2008).Arylamine carcinogens undergo N-acetylation, and Nhydroxy-arylamine carcinogens undergo O-acetylation in human liver cytosol (reviewed by Hein, 1988). The Nacetylation of arylamines and the O-acetylation of Nhydroxy-arylamine amines are ...