Changes in Biomarkers Associated With Use of Electronic Cigarettes Among African American Menthol and Nonmenthol Smokers
Phase: NA
Conditions: Biomarkers
Sponsor: University of Minnesota

 
ClearWay e-Cig Study - 1509M78241 
Protocol Version 5_9/8/2017 
 
 
 
 
 
Protocol 
 
 
 
Changes in Biomarkers Associated with Use of Electronic Cigarettes among African 
American Menthol and Nonmenthol Smokers 
 
 
 
 
PI: Anne Joseph, MD, MPH 
 
 
 
 
Version: 6 
Date:   7/26/2019 
 
 
 
 
CPRC#: 2015NTLS139 
IRB#: 1509M78241 
ClinicalTrials.gov#: NCT03084315 
CTSI ID: 24127 
 
 
 
 
 
 
 
 
 
 
 

 
ClearWay e-Cig Study - 1509M78241 
Protocol Version 5_9/8/2017 
 
 
Specific Aims 
In this study, a 2-group randomized design will be used to evaluate changes in biomarkers 
associated with the use of e-cigarettes with and without nicotine among African American menthol 
and nonmenthol cigarette smokers. 240 smokers (all African American) will be randomized into one of 
two study groups including 1) Active e-cigarettes (containing nicotine), or 2) nicotine-free e-cigarette 
(containing 0mg nicotine). Within each study condition, participants will be allowed to select their 
preferred flavor (menthol or non-menthol) of electronic cigarettes after sampling both flavors. ) 
Blocked randomization will be performed to ensure balance in the number of intervention assignments 
between the study groups (i.e., active e-cigarette versus nicotine-free e-cigarette). The power 
calculation for this study is based a two-sided two-sample equal-variance t-test on the primary 
outcome of NNAL (pmol/mg creatinine) at week 6 (active e-cig group vs. control e-cig group), and 
assumes an alpha of 0.05, and an NNAL standard deviation of 0.80. With a sample size of 200 
completers, this study will have 80% power to detect a difference in NNAL between the active and 
placebo e-cig groups of at least 0.4 standard deviations at week 6 (mean difference of 0.32 pmol/mg 
creatinine).  
All participants will be provided with e-cigarettes for ad lib use based upon the study 
randomization assignment. Follow-up assessments will be conducted at 2, 6, and 12 weeks post 
randomization. Primary outcomes will be changes in biomarkers, including total nicotine exposure 
(TNE) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL).  Secondary outcomes will be the 
patterns of use of combustible cigarettes and electronic cigarettes including dual use.  
Primary Aim: To compare the effect of electronic cigarettes with nicotine to electronic 
cigarettes without nicotine on NNAL (a biomarker related to the use of combustible cigarettes) among 
African American menthol and non-menthol smokers. 
Primary Hypothesis:  At 6 weeks post-enrollment, there will be a greater reduction in NNAL 
among participants using electronic cigarettes with nicotine compared to participants using electronic 
cigarettes without nicotine. 
Secondary Aim: To compare the effect of electronic cigarettes with nicotine to electronic 
cigarettes without nicotine on smoking behavior (combustible cigarettes) among African American 
menthol and non-menthol smokers. 
Secondary Hypothesis:  At 6 weeks post-enrollment, there will be a greater reduction in use of 
combustible cigarettes among participants using electronic cigarettes with nicotine compared to 
participants using electronic cigarettes without nicotine. 
 
Significance 
Approximately 1 in 4 adult smokers in the U.S. smoke mentholated cigarettes.1 However, there 
is substantial variation in the use of mentholated cigarettes.1  Up to 80% of African American smokers 
use mentholated cigarettes compared to approximately 25% of non-Hispanic white smokers.2 African 

 
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Americans also experience disproportionately high rates of lung cancer2 and other smoking-related 
diseases.3, 4 Studies by our research team5-7 and others8 have suggested that mentholated cigarettes 
are more addictive and associated with lower quit rates compared to non-mentholated cigarettes. 
However, not all studies have found this association.9, 10 The pattern of use of mentholated cigarettes 
in Minnesota is consistent with national data in that 22% of smokers used mentholated cigarettes in 
2010 and the rates of menthol use is highest among priority populations including African Americans, 
unemployed, and low-income smokers. 
The Family Smoking Prevention and Tobacco Control Act enacted by the U.S. Congress in 2009 
gave the Food and Drug Administration (FDA) the authority to regulate tobacco products. In July 2011, 
the FDA’s Tobacco Products Scientific Advisory Committee (TPSAC) submitted its final report with a 
recommendation that “removal of menthol cigarettes from the marketplace would benefit public 
health in the U.S.”. Although the FDA has yet to issue its final decision on the TPSAC report, one 
possible action could be a ban of mentholated cigarettes by the FDA from U.S. markets. A number of 
studies have examined what might happen if menthol cigarettes were to be banned from the U.S. 
markets. In a recent survey, 471 adolescents and adult smokers were asked a series of questions about 
how they might react if menthol cigarettes were banned.11 Thirty-five percent of menthol smokers said 
they would quit smoking if menthol cigarettes were banned while 25% said they would “find a way to 
buy a menthol brand”. In another study, researchers used data from the 2003 Tobacco Use 
Supplement to Current Population Survey to project the impact that a menthol ban would have on 
smoking prevalence and smoking attributable deaths.12 Results showed that in a scenario in which 30% 
of menthol smokers quit and 30% of those who would have initiated as menthol smokers do not 
initiate, the relative reduction in smoking prevalence would be 9.7% overall and 24.8% for blacks by 
2050. These studies suggest that a ban on menthol cigarettes could result in 3 million menthol smokers 
deciding to quit smoking, the majority of whom will be ethnic minorities and other at-risk groups. Even 
if menthol cigarettes were not banned, it is possible that menthol smokers seek other methods to 
obtain nicotine that might impact their use of a combustible cigarette product that might include the 
use of non-combustible nicotine product such as electronic cigarettes. However, there is no published 
about the pattern of use of e-cigarettes by menthol smokers in particular and African Americans in 
general. 
Electronic cigarettes represent a dramatic new nicotine delivery technology and are an 
emerging health issue. Since their being introduced in the United States in 2007, e-cigarettes sales 
have been doubling annually and are projected to surpass the $2 billion mark in sales in 2013.13, 14 Also, 
in some countries as many as a third of current or recent ex-cigarette smokers have tried e-
cigarettes.15-17 In the U.S., the most recent data from a representative national sample of adults 
reported that 4.2% of adults used e-cigarettes everyday, some days or rarely.18 Given the increasing 
popularity of e-cigarettes, there is a compelling need to understand the pattern of use across various 
populations, characteristics of users, effects on nicotine and other toxicant exposure. This is even more 
important among minority and other at-risk populations including African Americans that experience 

 
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disproportionate burden of tobacco-related health effects. The proposed study is therefore designed 
to determine the biomarkers associated with the use of e-cigarettes with and without nicotine by 
African Americans smokers; and to determine the patterns of use of electronic cigarettes among 
African American smokers. This study has high potential to contribute significant new knowledge that 
could be invaluable for reducing the burden of tobacco-related health problems in Minnesota and 
beyond. 
Furthermore, the distributors of e-cigarettes promote them as free of harmful substances 
claiming that e-cigarettes do not deliver toxic doses of nicotine.13, 19 However, a recent report by an 
NIH Workshop on e-cigarettes13 reported that analysis of aerosols from several brands of e-cigarettes 
revealed differences in their efficacy and consistency of nicotine aerosolization which is attributed to 
differences in device design including heating elements, cartridge size, and battery strength.13 Also, 
recent studies have reported the presence of trace amounts of nitrosamines and other potentially toxic 
compounds.19, 20 However, the levels of potentially toxic compounds in e-cigarette vapor are 9-450-fold 
lower than those in the smoke of combustible cigarettes.13 Our research team recently completed a 
ClearWay-funded pilot study to determine product preferences of menthol cigarette smokers (n=53) 
when they were asked to stop smoking. Menthol smokers tested a number of products including 
nicotine replacement therapies (regular and mint-flavored nicotine gum) and electronic cigarettes 
(menthol and non-menthol brands) and ranked their product preferences. Menthol smokers 
overwhelmingly (75%) selected menthol e-cigarettes to help them during a cigarette abstinence phase. 
The proposed study builds on findings from our prior work by seeking to evaluate the patterns of use 
of electronic cigarettes among African American smokers and biomarkers associated with use of e-
cigarettes. 
Although the role of electronic cigarettes in tobacco control is controversial,21, 22 there is 
paucity of data to inform the debate.  Limited available data show that e-cigarettes are used by 
millions in the US and other countries.23  In a 4-country survey24 that included the USA, Canada, U.K. 
and Australia, respondents reported using e-cigarettes for a variety of reasons including in smoke free 
zones (85%), for reducing smoking (80%), because it is perceived to be less harmful (75%), or to quit 
smoking (70%).  Other studies suggest that e-cigarettes are capable of delivering nicotine into the 
bloodstream and reducing withdrawal as effectively as NRTs.25, 26 It is important to note, however, that 
while e-cigarette users may have reduced their cigarette smoking, smoking fewer cigarettes may not 
confer any real reduction in total nicotine exposure or in the risk of tobacco-related diseases.27, 28 None 
of the studies described above reported data on the patterns of e-cigarette use by African Americans. 
Because African Americans are disproportionately impacted by tobacco-related diseases, data on the 
pattern of use of e-cigarettes among African Americans is critical. African Americans have also been 
shown to metabolize nicotine differently than whites. Studies are therefore needed to determine 
whether African American smokers who use e-cigarettes without the intent of quitting smoking reduce 
their exposure to nicotine and tobacco-specific carcinogens. Also, although there has been a lot of 
focus on African American menthol smokers, at least 20%-25% of African American smokers and 75%-

 
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80% of white smokers smoke non-mentholated cigarettes.1 Some studies have shown slightly better 
outcomes for AA menthol compared to nonmenthol smokers.5-7 Studying AA menthol and nonmenthol 
smokers in the same study would provide the opportunity to evaluate potential differences in 
outcomes by menthol status in the pattern of use of e-cigarettes and biomarkers of exposure to e-
cigarettes. The primary aim of the current application is to determine the biomarkers associated with 
the use of electronic cigarettes among African American menthol and nonmenthol smokers.. The study 
will also assess differences in patterns of use of e-cigarettes between African American menthol and 
nonmenthol smokers and e-cigarettes with and without nicotine.  
Unfortunately, clinical studies assessing the efficacy of e-cigarette for smoking cessation per se 
cannot begin without an Investigational New Drug (IND) for a chosen e-cigarette from the FDA;13 IND 
approval requires a level of product data and manufacturing documentation that is currently not 
available to researchers. Efforts by our research team as well as other researchers to obtain an IND 
approval from the FDA have been unsuccessful. In view of the barrier created by the current FDA policy 
requiring IND approval for e-cigarettes, it has therefore become necessary to amend the design of the 
proposed study from a treatment study to one that will assess the patterns of use of e-cigarettes and 
changes in biomarkers of exposure among African American smokers. 
Because the primary outcome of the amended design is changes in biomarkers among smokers 
not intending to quit rather than smoking cessation, it is our belief that IND is not required. Under 
current FDA regulatory environment, the amended design represents the best possible science that 
uses a randomized controlled design to fill critical gap in the tobacco control literature regarding the 
patterns of use of e-cigarettes among African American smokers. The proposed study is informed by 
findings from our formative research which demonstrated an overwhelming preference for menthol e-
cigarettes by African American menthol smokers and therefore represents an important step for 
developing an evidence base for about e-cigarette use in this priority population and its impact on 
potential harm.  
 
Preliminary Evidence 
 
Our research team recently completed a ClearWay-funded pilot study (n=53) to determine 
cessation treatment preferences of menthol cigarette smokers in which menthol smokers tested six 
products including four types of nicotine gum (2mg & 4mg plain;  2mg & 4mg mint-flavored) and two 
flavors of electronic cigarettes (16mg menthol and non-menthol). Study enrollment was completed in 
about six weeks. Participants were all African American menthol smokers, 53% male, mean age 45.5 
(SD=11.5) years, smoked 14.2 CPD at baseline (SD=5.1). 
  
Of the 53 smokers who completed product selection phase, 73.5% selected menthol e-
cigarettes, 18.9% selected non-menthol e-cigarettes, and 7.5 % selected 2mg mint nicotine gum for 
smoking cessation. At the final week six follow-up visit (after two weeks of using selected product), 

 
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participants on average smoked 4.5 CPD; they reported using 8.7 e-cigarettes total for the 2-week 
cessation phase (<1 e-cig/day); and four participants had quit smoking tobacco cigarettes. 
  
Findings from our formative research informed the proposed study in a number of ways 
including, 1) the formative research showed that African American menthol smokers will engage in a 
clinical research that includes the use of e-cigarettes. Given that recruitment of the 50 participants was 
completed in less than two months with minimal attrition, established the feasibility of recruitment for 
the proposed study; 2) African American menthol smokers overwhelmingly preferred menthol e-
cigarettes compared to other tested products as a smoking cessation aid. This finding informed our 
choice of menthol e-cigarettes for the proposed study; and 3) given the absence of data on the 
patterns of use of e-cigarettes and the impact of use on biomarker of exposure, a natural step is for a 
study to evaluate the effects of e-cigarette on smoking behavior in this population 
 
 
Innovation 
 
The proposed study is innovative in that it will be the first to determine the biomarkers 
associated with the use of e-cigarettes among African American menthol and nonmenthol smokers, 
and to determine the pattern e-cigarette use among this priority population. In addition, this study will 
examine the role of nicotine in pattern of e-cigarette use and biomarkers of exposure.  
Both nationally and in Minnesota, racial/ethnic minorities as well as other at risk groups (e.g. 
youth, low SES) smoke menthol cigarettes at disproportionately high rates compared to the general 
population. These groups also experience disproportionately higher rates of tobacco-related socio-
economic and health consequences compared to the general population. The proposed research will 
examine patterns of use of e-cigarettes among smokers of combustible cigarettes in this priority 
population of smokers and the impact of these behaviors on biomarkers of exposure. Such information 
is critical to addressing use of tobacco products among at-risk smokers in Minnesota and nationally.  
 
Approach 
 
A total of 240 (all African American smokers) will be randomized 1:1 into one of two groups: 
nicotine-containing electronic cigarettes or nicotine-free electronic cigarettes. All participants will be 
provided with e-cigarettes by the study, based upon the study randomization assignment and be 
asked to use ad lib. Follow-up assessments will be conducted at 2, 6, and 12 weeks post 
randomization. Primary outcomes will be assessment of urinary biochemical markers NNAL (tobacco-
specific carcinogen) and total nicotine exposure (not specific to tobacco) (TNE). Secondary outcomes 
will be the patterns of use of combustible cigarettes and e-cigarettes. 
Inclusion criteria: 1) self-identify as African American or Black; 2) age 18 years or older; 3) 
smoke at least five cigarettes daily for the past year; 4) Willing to use e-cigarettes;  5) Good physical 

 
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health (no unstable medical or mental health condition); 6) no contraindications for e-cigarette use; 
and 7) does not have a set quit-date in the next 30 days. 
         
Exclusion criteria: 1) Recent unstable or untreated psychiatric diagnosis including substance 
abuse, as determined by the DSM-IV criteria; 2) use in the past 30 days of e-cigarettes;  3) pregnant or 
nursing.  
Recruitment: will utilize methods we have successfully used in previous studies with African 
American smokers33-36 including flyers at African American community, clinic, and university sites and 
events, paid advertisement in targeted newspapers, radio, and email panels with predominantly large 
African American audience. We will also post advertisements on Facebook and create a study 
Facebook page. Lastly, we will send recruitment letters to Fairview patients using the Fairview 
Research Recruitment Mailing service. In order to complete this process we will develop a mailing list 
through CTSI. Fairview will receive the mailing list and then work with UMN Addressing and Mailing to 
send our recruitment letter along with a Fairview cover letter to potential participants. Potential 
participants will then contact the study coordinator if they are interested in participating. 
Randomization Scheme: Randomization will occur at the individual level at the baseline 
assessment. The study statistician will provide the study coordinator with group assignments in sealed 
envelopes that will only be opened after study staff have confirmed eligibility and completed final 
consent. To ensure balance in the number of intervention assignments between the study groups (i.e., 
active e-cigarette versus nicotine-free e-cigarette),blocked randomization will be performed and the 
size and sequence of which will only be known to the statistician. 
 
Study Procedures 
Baseline/Randomization visit: At this visit the study’s goal and procedures as well as participant 
responsibilities will be reviewed with each participant. Those who are interested will sign a consent 
form and be asked to complete an expired carbon monoxide assessment to verify smoking status. If 
expired carbon monoxide is <8ppm, then a urine sample will be collected and tested with urine strips 
for the presence of cotinine. If expired carbon monoxide is <8ppm and cotinine is not detected in the 
urine, the participant will be ineligible.  Eligible participants will complete baseline assessments 
including demographics, tobacco use, and nicotine dependence measures. Participants will then be 
randomized to receive either active e-cigarettes (containing nicotine), or nicotine-free e-cigarette 
(containing 0mg nicotine). Within each study condition, participants will be allowed to select their 
preferred flavor (menthol or non-menthol) of electronic cigarettes. Prior to selection of their preferred 
flavor, participants will be allowed to sample both menthol and non-menthol flavored brands of e-
cigarettes by taking a few puffs from both brands during the visit. Participants will receive enough 
supply of study products to last until their next appointment plus 7 days extra for scheduling flexibility. 
All participants will be provided verbal and written usage instructions for e-cigarettes. They will be 
instructed to bring all, used and unused, e-cigarettes to every visit for product count as one of the 
measures of adherence. Urine will also be collected to assess NNAL and TNE. 

 
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Weeks 2 and 6: Approximately three days before each of these visits, participants will be 
contacted by study staff through reminder card and by phone. At these visits participants will update 
their contact information and complete a brief survey (combustible cigarettes and e-cigarettes use, 
withdrawal symptoms, etc), take expired CO test, and receive more e-cigarettes (week 2 only) to last 
until  their week 6 visit. Study staff will check and record if participant has been actively using their e-
cigarettes and count returned e-cigarettes. Urine will also be collected at week 6 to assess NNAL and 
TNE.  
         
Week 12: Participants will complete a survey over the phone. 
         
Compensation:  Participants will be compensated for their time and transportation to minimize 
attrition. Based on our experiences in previous studies participants will receive $40 at baseline and 
week 2, $50 at week 6 visit, and $20 at week 12, for a maximum of $150 per participant over 12 weeks. 
Nicotine E-Cigarette Arm: Participants will receive an active (brand and dose TBD) e-cigarette 
with the flavor of their choice. Participants will each be dispensed a free rechargeable e-cigarette 
starter kit with the necessary accessories at the randomization visit plus enough supplies at this visit 
and the week 2 visit for a total supply of 6 weeks. Trouble shooting support will be provided as well as 
phone numbers for both technical and medical assistance related to the use of e-cigarettes. Follow-up 
visit schedule and all other study protocol for participants in each arm will be the same. Although the 
study will only provide participants with e-cigarettes for 6 weeks, they will be told that they are 
allowed to purchase their own if needed after 6 weeks. 
   
Nicotine-free E-cigarette arm:  Participants will receive e-cigarettes containing 0mg nicotine 
with the same protocol described for the active e-cigarette arm above. 
  
Human Subjects Protection: 
This study will enroll 240 smokers, all African American. Inclusion and exclusion criteria have 
been discussed earlier in the proposal. Before any research is conducted, we will obtain IRB approval 
for the study protocol and informed consent documents. Data will be obtained exclusively for research 
purposes. 
Potential Risks:  The use of the e-cigarettes will be under supervision of Dr. Joseph. The e-
cigarettes will be discontinued in patients who become pregnant or develop a contraindication. 
Patients will be told that e-cigarettes are not approved by FDA as a smoking cessation aid. Some 
studies have found that the levels of the toxicants in e-cigarettes are 9-450 times lower than in 
cigarette smoke and were, in many cases, comparable with trace amounts found in nicotine inhaler, an 
FDA-approved smoking cessation product.37 Participants will be told even though there are no long 
term health impact data, there are some studies showing more immediate effects from e-cigarette use, 
e.g. decreased Fractional exhaled Nitric Oxide (FeNO), increased respiratory resistance and retardation 
of lung function,38 and one case of lipoid pneumonia.39 Another study reported that, exposure to 
propylene glycol mist for 1 minute was associated with decrease in  a person’s tear film stability, 
increase in ocular and throat symptoms, and slight reduction in forced expiratory volume in 1 

 
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second/forced vital capacity (FEV1/FVC), and increase in self-rated severity of dyspnea.40 We will 
follow the NIH guidelines for reporting adverse events to the Institutional Review Board. Any problems 
needing medical attention will be referred to Dr. Joseph and the participant’s healthcare provider.  
  
Data Collection (Measures):  
Due to the literacy level of the target population, if needed all questionnaire items will be read 
to, or along with participants, by a trained research assistant.41 A number of these measures were used 
in our pilot project and other studies with African American smokers. 
 
Outcomes 
   
Cigarette Smoking Behavior. Use of combustible cigarettes will be characterized in a variety of 
ways.  These include, for example, smoking status; number of cigarettes smoked per day, per week, 
and per month; smoking history (age when first smoked); quitting history; and cigarette brand smoked 
(menthol vs. nonmenthol). These questions have established validity and reliability, and have been 
used in a sample comparable to the one planned for the current study.5, 7 Use of e-cigarettes will be 
assessed at baseline and weeks 2, 6, and 12 using one item from the Penn State  Electronic Cigarette 
Dependence Index42 which asks the participant, “How many times per day do you usually use your 
electronic cigarette?” (assume that one “time” consists of around 15 puffs or lasts around 10 minutes); 
scoring: 0-4 times/day = 0, 5-9 = 1, 10-14 = 2, 15-19 = 3, 20-29 = 4, 30+ = 5). Total NNAL can be used to 
validate the use of only e-cigarettes because NNK is not present in the fluids used in e-cigarettes but is 
present in tobacco products.   We will calculate total NNAL/total cotinine ratio.  If no other tobacco is 
used, then the ratio should be low. Dr. Hatsukami has extensive experience in the use of NNAL to 
validate tobacco use status. 
Demographics: The demographic data that will be collected in the study includes housing, 
gender, education, marital status, age, income, and employment status. 
Nicotine Dependence: We will assess using the 1-item Time to First Cigarette question taken 
from the Fagerstrom Test for Nicotine Dependence (FTND) to assess dependence to combustible 
cigarettes.43 Dependence on e-cigarettes will be assessed at weeks 2, 6, and 12 using the 10-item Penn 
State Electronic Cigarette Dependence Index.42 This scale has been validated with a large sample of ex-
smokers and e-cigarette users. 
Withdrawal Symptoms: We will use the modified scale developed by Hughes and Hatsukami.44 
Items in the scale include desire to smoke, irritability (anger, frustration), anxiety (nervousness), 
difficulty concentrating, restlessness (impatience), hunger, depression, and awakening. Responses will 
be summed to create a withdrawal severity index and used as covariates in our analyses. 
Readiness to quit:  We will use the 1-item Contemplation Ladder,45, 46 an 11-point Likert-type 
scale with 10 rungs, and is anchored at every point. 

 
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Other substance abuse: Questions to assess alcohol and other substances will be derived from 
National Household Survey on Drug Abuse.47 These measures will be used as moderators of 
intervention components. 
 
Biomarker assessment: The primary biomarkers that will be evaluated include urinary total 
NNAL and total nicotine equivalent (TNE).  The urinary biomarkers will be assessed at baseline and 
week 6. We will also assess expired carbon monoxide (CO) using a hand held, portable CO monitor 
(Bedfont Micro Smokerlyzer, Kent, England).  We will use 8 ppm as the cut-off to verify smoking status 
as recommended by the SRNT Subcommittee on Biochemical Verification.48 Our group has extensive 
experience with biochemical verification of smoking.7, 33, 35, 49 Expired CO will be measured at all in-
person visits. If expired CO is <8ppm, a urine test strip will be used to detect the presence of 
nicotine/cotinine. We will also calculate total NNAL/total cotinine ratio. The TNE and NNAL analysis will 
be conducted by the lab of Dr. Sharon Murphy at the University of Minnesota.  
 
 

 
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Table 1. 
Procedures 
Summary 
  
  
  
  
  
  
Visit/contact 
 Screening 
1 
2 
3 
4 
Time 
 7-14 days 
 Baseline/ 
Randomization 
Week 
Week 
Week 
  
before Week 0 
Week 0 
2 
6 
12 
(by phone) 
Visit Duration (Minutes) 
  
75 
 45 
45 
30 
Procedures 
  
  
  
  
  
Consent, Pregnancy test* 
  
X 
  
  
  
Weight, Height 
  
X 
  
X 
 
Expired Carbon Monoxide 
  
X 
X 
X 
 
NicAlert (if CO is <8ppm) 
 
X 
 
 
 
Intervention 
  
  
  
  
  
Active/Placebo E-
Cigarettes administered 
  
X 
X 
 
  
Outcomes 
  
  
  
  
  
Biomarkers (TNE, NNAL) 
  
X 
  
X 
   
E-cigarette count  
  
  
X 
X 
X 
Cigarettes per day  
 X 
X 
X 
X 
X 
Timeline follow back 
 
X 
X 
X 
 
Predictors 
  
  
  
  
  
Demographics 
  X 
X 
  
  
  
Smoking History 
X 
X 
X 
X 
X 
Nicotine withdrawal 
  
X 
  X 
 X 
 
Nicotine dependence 
 
 
  X 
 X 
X   
Readiness to quit smoking 
X 
X 
X 
X 
X 
Product evaluation 
  
  
X 
X 
 X 

 
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Rationale for Study Design 
1)          Overall design: The current study design was informed by findings from our formative 
study that showed that African American menthol smokers overwhelmingly selected menthol e-
cigarette for smoking cessation. Using a randomized design would reduce potential differences in 
smoking behavior (e.g. CPD, motivation and confidence to quit, quit attempts, psychosocial factors, 
etc) between study groups that might impact the outcomes of interest. A 2-group randomized design 
will be used to evaluate the patterns of use of e-cigarette and the impact of use on biomarkers of 
exposure. 
  
2)         How was the brand and dose of e-cigarette selected? In our recently completed pilot 
study, we used the Blu e-cigarette (approximately 13-16mg nicotine) which is among the most 
commonly used and widely available e-cigarettes. The product was well-liked and well-tolerated by 
participants. However, there are more recent generations of e-cigarettes that may deliver a higher 
amount of nicotine. Therefore, if this proposal is funded, we will review all available options in the 
market and consider factors such amount of nicotine delivered, price, and affiliation of manufacturer 
with tobacco industry in final product selection with guidance from Dr. Hatsukami, an e-cigarette 
expert on our team. 
 
3)         Why limit study sample to African Americans? There are well-documented differences in 
smoking patterns and nicotine metabolism between African Americans (AAs) and whites. These include 
the fact that AAs smoke fewer cigarettes per day and predominantly smoke menthol cigarettes.29 AAs 
also have higher cotinine levels per cigarette smoked than whites.30 Differences in smoking patterns 
and nicotine metabolism in specific populations could introduce variability that masks potential 
differences in how smokers use e-cigarettes effects. Also, in the TPSAC report to the FDA, the 
population that had lower success rates for smoking cessation among menthol smokers compared to 
non-menthol smokers was predominantly African American 
(http://www.fda.gov/downloads/AdvisoryCommittees/ 
CommitteesMeetingMaterials/TobaccoProductsScientificAdvisoryCommittee/UCM269697.pdf). 
 
4  
 
 
 
Table 2. Project Timeline 
  
Year 1 
Year 2 
Year 3 
Months: 
1-4 
5-8 
9-12 
13-16 
17-20 
21-24 
25-28 
29-32 
33-36 

 
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IRB processing, Protocol 
revision and 
refinement/pilot 
  
  
  
  
  
  
  
  
  
  
Recruitment of 300 
participants into the 
study 
  
  
  
  
  
  
  
  
  
  
e-cigarette use phase 
  
  
  
  
  
  
  
  
  
  
Follow-up phase 
  
  
  
  
  
  
  
  
  
Data entry and analyses 
  
  
  
  
  
  
  
  
  
  
Manuscripts & 
presentations /R01 
Submission 
  
  
  
  
  
  
  
  
  
  
 
Power Calculation 
The power calculation for this study is based a two-sided two-sample equal-variance t-test on 
the primary outcome of NNAL (pmol/mg creatinine) at week 6 (active e-cig group vs. control e-cig 
group), and assumes an alpha of 0.05, and an NNAL standard deviation of 0.80.50 With a sample size of 
200 completers, this study will have 80% power to detect a difference in NNAL between the active and 
placebo e-cig groups of at least 0.4 standard deviations at week 6 (mean difference of 0.32 pmol/mg 
creatinine). This is appropriate given a prior study with similar methods saw a decrease in NNAL of 
approximately 0.3 pmol/mg from baseline to week 6 among smokers that switched to reduced nicotine 
cigarettes (CENIC, n=196, p=0.02).51 
For example, if the control e-cig group has no reduction in NNAL from baseline to week 6 (i.e. 
1.50 to 1.50 pmol/mg creatinine), this study will be powered to detect a difference between study 
groups with at least a 21% reduction in NNAL in the active e-cig group (i.e. 1.50 to 1.18 pmol/mg 
creatinine). When comparing expected NNAL at week 6 between the two groups (active: 1.18 vs. 
control: 1.50 pmol/mg creatinine), the NNAL ratio is 0.79. This is comparable to the results in CENIC, 
which found a statistically significant NNAL ratio of 0.78 comparing participants that used 15mg/g 
cigarettes vs. participants that used reduced nicotine cigarettes (0.4mg/g) at week 6 (CENIC, n=196, 
p=0.02; Donny et al. 2015). To ensure that we have 200 participants complete the week 6 visit, we will 
inflate the randomization number by 20%, to 240 randomized, or 120 per group. This power 
calculation was completed using SAS Software v.9.4 (SAS Institute Inc., Cary, NC). 
 
 

 
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Analysis Plan 
Prior to initiating outcome analyses of quantitative data, we will examine frequency 
distributions for all variables, with particular attention to variable ranges, missing values, and 
skewness, and will log-transform variables as necessary. Using t-tests for continuous data and chi-
square tests for categorical data, we will examine randomization group comparability at baseline to 
determine whether randomization was successful in creating equivalent groups with regard to the 
demographic variables and baseline characteristics (i.e. age, gender, cigarettes smoked per day, 
nicotine dependence, and menthol vs. regular cigarette smoker). These analyses, along with a priori 
reasoning will help determine whether there is a need to incorporate covariates into later analyses. 
Primary analyses: The primary outcome for the study will be NNAL at week 6. We will compare 
week 6 NNAL between the two study groups, adjusted for baseline NNAL in generalized linear 
regression models. Covariates that will be considered include age, sex, income or educational level, 
and menthol status. To test for a within-subject change in NNAL from baseline to week 6, paired t-tests 
will be used within randomization group.  
Secondary analyses: Differences in our secondary measures between the two study groups will 
be assessed using the appropriate methods (e.g., logistic regression for binary and binomial outcomes, 
linear regression for continuous outcomes; using their Generalized Estimating Equations or mixed 
model analogs when the outcomes were repeatedly measured within person). Specifically, differences 
in smoking behavior between the two groups will be assessed by comparing the change in average 
number of cigarettes per day on the 7 days preceding the baseline visit to each study time point (week 
2, week 6, and week 12). Other secondary measures that will be compared between the two groups 
may include: change in TNE from baseline to follow up visits, e-cigarette use from baseline to week 6, 
e-cigarette use from week 6 to week 12, and e-cigarette product evaluation.  
         
Data Management: Data management activities for this project will encompass data entry, data 
cleaning, identifying and tagging any crossovers, conversion into proper format for data analysis and 
recoding. REDCap will be used for designing, implementation and maintenance of the database. In 
addition, a computer based tracking system will be developed to follow each patient and to prompt 
the staff for the upcoming data collection point. Data collection points for each subject will be 
calculated from his or her initial date of contact. Data entry will be performed at the University of 
Minnesota. Codebooks will be developed and will include variable formats (numeric/alpha), min/max 
ranges and any skip patterns.  
 
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