A Randomised, Cross-over, Relative Bioavailability Study of Nicotine Delivery and Nicotine Extraction From Oral Products (Traditional Snus, Conventional Cigarette and Three Oral Tobacco-free Nicotine Delivery Products)
Phase: NA
Conditions: Healthy Volunteers
Sponsor: Imperial Brands PLC

A RANDOMISED, CROSS-OVER, RELATIVE BIOAVAILABILITY STUDY OF 
NICOTINE DELIVERY AND NICOTINE EXTRACTION FROM ORAL TOBACCO 
PRODUCTS (TRADITIONAL SNUS, CONVENTIONAL CIGARETTE AND THREE 
ORAL TOBACCO-FREE NICOTINE DELIVERY PRODUCTS) 
 
 
NCT# NCT04891406 
 
 
 
Study Protocol - FINAL v2.0, 26AUG2020 
 
 
 
 

 
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Clinical Study Protocol 
 
 
Investigational Product 
ZoneX #2, ZoneX #3 
 
Sponsor study code 
IB-OND-PKZX-01 
 
Protocol Version and Date 
FINAL v2.0; 26AUG2020 
 
 
 
A RANDOMISED, CROSS-OVER, RELATIVE BIOAVAILABILITY STUDY OF 
NICOTINE DELIVERY AND NICOTINE EXTRACTION FROM ORAL TOBACCO 
PRODUCTS (TRADITIONAL SNUS, CONVENTIONAL CIGARETTE AND THREE 
ORAL TOBACCO-FREE NICOTINE DELIVERY PRODUCTS) 
 
Phase 
I 
Indication 
Healthy volunteers 
Test product and dose 
ZoneX #2 (oral nicotine delivery product [OND]), 
5.8 mg nicotine/pouch 
ZoneX #3 (OND), 10.1 mg nicotine/pouch 
Comparator product and dose 
Skruf Snus fresh slim white, 10.9 mg 
nicotine/pouch 
 
Marlboro Gold, conventional cigarette,  
0.8 mg nicotine/cigarette 
 
Sponsor signatory 
 
Imperial Tobacco Ltd  
121 Winterstoke Road 
Bristol BS3 2LL, United Kingdom 
Principal Investigator 
 
CTC Clinical Trial Consultants AB 
Dag Hammarskjölds väg 10B 
SE-752 37 Uppsala, Sweden 
Clinical study conduct and 
management 
CTC Clinical Trial Consultants AB 
Dag Hammarskjölds väg 10B 
SE-752 37 Uppsala, Sweden 
 
 

 
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1 
STUDY SYNOPSIS 
Study title 
A randomised, cross-over, relative bioavailability study of nicotine delivery and nicotine 
extraction from oral tobacco products (traditional snus, conventional cigarette and three oral 
tobacco-free nicotine delivery products) 
Study code 
IB-OND-PKZX-01 
Planned study period 
Q3 2020 to Q4 2020 
Phase of development 
I 
Principal Investigator 
 
CTC Clinical Trial Consultants AB 
Dag Hammarskjölds väg 10B 
SE-752 37 Uppsala, Sweden 
Study design 
This will be a randomised cross-over, open-label, confinement study conducted in 24 male or 
female snus and cigarette consumers. The study will investigate 5 different nicotine 
containing products in a cross-over fashion. Cross-over in design, the study will incorporate 
pharmacokinetics evaluation, nicotine extraction evaluation, subjective questionnaire 
assessments as well as safety evaluation. 
During the study participation, subjects will come for 2 visits to the clinic, including a 5-day 
confinement period and finally a follow up end-of-study telephone call within a week of 
product use. 
Objectives  
Primary objective 
To evaluate and compare the maximum plasma concentration (Cmax) and the area under the 
curve at the last timepoint measured (AUCt) of nicotine after the use of each product. 
Secondary objectives  
To evaluate other pharmacokinetic parameters of nicotine after the use of each product. 
To evaluate extracted dose of nicotine in used products. 
To evaluate product perception and preference by use of subjective assessments. 
To evaluate the tolerability and safety of each of the products used. 
To evaluate the total nicotine exposure by measuring cotinine following single and ad lib use 
of each of the products. 
Endpoints 
Primary endpoints 
• Cmax and AUCt  

 
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Secondary endpoints 
• AUC timepoint 0 to 90 minutes (AUC0-90), AUC timepoint 0 to infinity (AUCinf), 
time to Cmax (Tmax), plasma concentration at last timepoint measured (Clast), and 
terminal elimination half-life (T1/2) 
• The extracted dose of nicotine from each portion, will be calculated to evaluate the 
correlation between AUC and extracted dose of nicotine. 
• Subjective assessment endpoints from Heaviness of smoking index (HSI), Product 
evaluation scale (PES), Modified cigarette evaluation questionnaire (MCEQ), 
Products preference scale (PPS) 
• Frequency, intensity and seriousness of adverse events (AEs) 
• Clinically significant changes in laboratory parameters, vital signs and ECG 
• Assessment of total nicotine exposure following plasma cotinine levels 
(concentration and applicable calculated PK parameters) following controlled single 
use and ad lib use of IP 
Number of subjects planned 
Approximately 48 subjects will be screened to achieve a total of 24 randomised subjects. 
Main eligibility criteria 
Male and female snus and cigarette consumers, aged ≥19 years and with a body mass index 
(BMI) of ≥ 18.0 and ≤ 30.0 kg/m2 will be considered for participation in the study. 
Pregnant or breastfeeding women, or subjects with other conditions believed to either put the 
subject at risk because of participation in the study, or influence the results or the subject’s 
ability to participate in the study, as judged by the Investigator, will be excluded from 
participation. 
Subject who intend to change their smoking habit, reduce or stop smoking within the next 
3 months will also be excluded.  Subjects wishing to make a quit attempt will be offered 
advice by the clinical team and provided with contact information for a nicotine cessation 
support service. 
Methodology 
Visit 1 (Screening)  
Visit 1 will take place from Day -28 to Day -1 and will include an eligibility check, review of 
health status and assessment of snus and cigarette consuming habits. Subjects will be 
provided with smoking cessation advice and contact information for a smoking cessation 
support service, should they request it. 
Visit 2 (In-clinic treatment period, Day -1 to Day 5) 
At Visit 2, subjects will be admitted to the clinic on the evening of Day -1 and will remain at 
the clinic until Day 5 for daily single IP use and PK, nicotine extraction, subjective 
questionnaire assessments and safety assessments. 
On the evening of Day -1, subjects will be undertaking baseline assessments for clinical 
laboratory profile, vital signs and ECG. Subjects are allowed to use their own snus product 
until 10pm on the evening of Day -1.  At 10pm, the subjects’ own nicotine containing 

 
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products will be collected by a member of the clinical team and returned upon completion of 
Day 5. 
On Day -1 the subjects will also undertake a familiarisation session of the study products and 
questionnaires. The clinical team will explain how the products will be used and the subjects 
will have the opportunity to see the product and packaging. An explanation of how the 
questionnaires will be administered to the subjects will be given. The familiarisation session 
does not include a product trial and all products used in the session will not be used in the 
clinical study but will be retained as demonstration samples for accountability purposes. 
In the morning of Day 1, after pre-use assessments and confirmation of eligibility, the 
subjects will be randomised and then administered a single pouch/single cigarette of the IP in 
the sequence to which they have been randomised. Oral nicotine IP will be used for 20 
minutes with standard use instructions. The cigarette will be smoked in approximately 5 
minutes with puffs taken at regular intervals approximately 30 seconds apart. PK sampling 
will be done pre-IP use and at 2, 5, 7, 15, 20, 30, 45, 60, 90 minutes, 2, 4, 6 and 8 hours post-
IP use start. Sampling for plasma cotinine levels will be taken pre-IP use and at 4, 8 and 12 
hours post-IP use start. Used pouches will be collected for analysis of nicotine extraction. 
Questionnaires will be administered to the subject at defined intervals throughout the day. 
Safety will be followed throughout the day. Subjects will be allowed to use the IP, to which 
they are assigned that day, ad lib after the 8-hour timepoint until 10 pm. 
In the morning of Day 2, after pre-IP use assessments, the subjects will be administered a 
single pouch/single cigarette of the IP in the sequence to which they have been randomised. 
IP will be used for 20 minutes with standard use instructions. The cigarette will be smoked in 
approximately 5 minutes with puffs taken at regular intervals approximately 30 seconds 
apart. PK sampling will be done pre-IP use and at 2, 5, 7, 15, 20, 30, 45, 60, 90 minutes, 2, 4, 
6 and 8 hours post-IP use start. Sampling for plasma cotinine levels will be taken pre-IP use 
and at 4, 8 and 12 hours post-IP use start. Used pouches will be collected for analysis of 
nicotine extraction. Questionnaires will be administered to the subject at defined intervals 
throughout the day. Safety will be followed throughout the day. Subjects will be allowed to 
use the IP, to which they are assigned that day, ad lib after the 8-hour timepoint until 10 pm. 
In the morning of Day 3, after pre-IP use assessments, the subjects will be administered a 
single pouch/single cigarette of the IP in the sequence to which they have been randomised. 
IP will be used for 20 minutes with standard use instructions. The cigarette will be smoked in 
approximately 5 minutes with puffs taken at regular intervals approximately 30 seconds 
apart.  PK sampling will be done pre-IP use and at 2, 5, 7, 15, 20, 30, 45, 60, 90 minutes, 2, 
4, 6 and 8 hours post-IP use start. Sampling for plasma cotinine levels will be taken pre-IP 
use and at 4, 8 and 12 hours post-IP use start. Used pouches will be collected for analysis of 
nicotine extraction. Questionnaires will be administered to the subject at defined intervals 
throughout the day. Safety will be followed throughout the day. Subjects will be allowed to 
use the IP, to which they are assigned that day, ad lib after the 8-hour timepoint until 10 pm. 
In the morning of Day 4, after pre-IP use assessments, the subjects will be administered a 
single pouch/single cigarette of the IP in the sequence to which they have been randomised. 
IP will be used for 20 minutes with standard use instructions. The cigarette will be smoked in 
approximately 5 minutes with puffs taken at regular intervals approximately 30 seconds 
apart.  PK sampling will be done pre-IP use and at 2, 5, 7, 15, 20, 30, 45, 60, 90 minutes, 2, 
4, 6 and 8 hours post-IP use start. Sampling for plasma cotinine levels will be taken pre-IP 
use and at 4, 8 and 12 hours post-IP use start. Used pouches will be collected for analysis of 
nicotine extraction. Questionnaires will be administered to the subject at defined intervals 

 
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throughout the day. Safety will be followed throughout the day. Subjects will be allowed to 
use the IP, to which they are assigned that day, ad lib after the 8-hour timepoint until 10 pm. 
In the morning of Day 5, after pre-IP use assessments, the subjects will be administered a 
single pouch/single cigarette of the IP in the sequence to which they have been randomised. 
IP will be used for 20 minutes with standard use instructions. The cigarette will be smoked in 
approximately 5 minutes with puffs taken at regular intervals approximately 30 seconds 
apart. PK sampling will be done pre-IP use and at 2, 5, 7, 15, 20, 30, 45, 60, 90 minutes, 2, 4, 
6 and 8 hours post-IP use start. Sampling for plasma cotinine levels will be taken pre-IP use 
and at 4 and 8 hours post-IP use start. Used pouches will be collected for analysis of nicotine 
extraction. Questionnaires will be administered to the subject at defined intervals throughout 
the day. Safety will be followed throughout the day. Subjects will leave the research clinic 
after completing all 8 h-assessments on Day 5. 
Visit 3 (End-of-Study phone call) 
A follow-up telephone call (Visit 3, end-of-study) will be made on Day 7 (±1) to follow-up on 
adverse events. 
Investigational Product (IP), dosage and mode of administration 
A:  ZoneX #2, oral nicotine delivery product (OND), white tobacco-free nicotine pouch, 5.8 
mg nicotine/pouch 
B:  ZoneX #3, OND, white tobacco-free nicotine pouch, 10.1 mg nicotine/pouch 
C:  Skruf snus fresh slim white, 10.9 mg nicotine/pouch 
D:  
 
E:  Marlboro Gold, conventional cigarette, 0.8 mg nicotine/cigarette 
Duration of IP use 
Single 20-minute use of each of the 4 oral nicotine products or a single cigarette use, 
followed by ad lib use of the product assigned that day until 10pm. 
Duration of each subject’s involvement in the study 
Subjects will participate in the study for up to 35 days, including an up to 28-day screening 
period. 
Pharmacokinetic (PK) assessments 
Blood sampling for nicotine and cotinine plasma concentration analysis 
Safety assessments  
AEs 
Clinical laboratory profile 
Vital signs (blood pressure and pulse) 
ECG 
Subjective measures 
PES, MCEQ, PPS 
Statistical methods 
No formal sample size calculation has been performed for this study. The proposed sample 
size is considered sufficient to provide adequate information for the study objectives. 

 
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Continuous data will be presented in terms of evaluable and missing observations, arithmetic 
mean, SD, median, minimum and maximum value. In addition, for the parameters AUC and 
Cmax the geometric mean and geometric coefficient of variation (CV) will be presented.  
Categorical data will be presented as counts and percentages. When applicable, summary 
data will be presented by treatment, and by assessment time. Individual subject data will be 
listed by subject number, treatment, and, where applicable, by assessment time. 
All descriptive summaries and statistical analyses will be performed using SAS Version 9.4 
or later (SAS Institute, Inc., Cary, NC). 
The primary objective will be examined by the following statistical comparisons for AUCt 
and Cmax: 
• Product A versus Product B, C, D and E, respectively 
• Product B versus Product C, D and E, respectively 
• Product C versus Product D and E, respectively 
• Product D versus Product E 
Log transformed nicotine Cmax and AUCt estimates will be evaluated separately in a linear 
mixed-effects analysis of variance model with fixed effects for period, sequence, and 
product, and a random effect for subject. If the assumptions for this model will be 
inappropriate will the fixed effects period and sequence be removed from the model. The 
above product differences will be back-transformed to present the ratios of geometric least 
squares (LS) means and 95% CIs of each test product versus each other from the same 
model. 
Study reporting 
After completion of the study a clinical study report (CSR) will be prepared.  
 
 

 
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2 
TABLE OF CONTENTS 
1 
STUDY SYNOPSIS .................................................................................................. 2 
2 
TABLE OF CONTENTS ......................................................................................... 7 
3 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ..................... 11 
4 
IMPORTANT MEDICAL PROCEDURES TO BE FOLLOWED BY THE 
INVESTIGATOR ................................................................................................... 13 
4.1 
Medical emergencies contacts ............................................................................... 13 
5 
INVESTIGATOR AND STUDY ADMINISTRATIVE STRUCTURE ............ 14 
6 
INTRODUCTION .................................................................................................. 16 
6.1 
Background ............................................................................................................. 16 
 
Summary of non-clinical data .............................................................................. 16 
 
Clinical experience ............................................................................................... 17 
6.2 
Study rationale........................................................................................................ 17 
6.3 
Risk/benefit assessment.......................................................................................... 17 
7 
STUDY OBJECTIVES AND ENDPOINTS ........................................................ 18 
7.1 
Primary objective and endpoints .......................................................................... 18 
7.2 
Secondary objectives and endpoints ..................................................................... 18 
8 
STUDY DESIGN .................................................................................................... 20 
8.1 
Overall study design and schedule of events ........................................................ 20 
8.2 
Rationale for study design ..................................................................................... 25 
9 
STUDY POPULATION ......................................................................................... 26 
9.1 
Recruitment ............................................................................................................ 26 
9.2 
Screening and enrolment log ................................................................................. 26 
9.3 
Number of subjects................................................................................................. 26 
9.4 
Inclusion criteria .................................................................................................... 26 
9.5 
Exclusion criteria.................................................................................................... 27 
9.6 
Restrictions during the study ................................................................................ 27 
 
General restrictions ............................................................................................... 28 
 
Prior and concomitant therapy.............................................................................. 28 
9.7 
Screen failures ........................................................................................................ 29 
9.8 
Subject withdrawal ................................................................................................ 29 
 
General withdrawal criteria .................................................................................. 29 
 
Procedures for discontinuation of a subject from the study ................................. 30 
 
Subject replacement.............................................................................................. 30 
9.9 
Randomisation ........................................................................................................ 30 
9.10 
Blinding ................................................................................................................... 30 
10 
TREATMENTS ...................................................................................................... 31 
10.1 
Identity of investigational products ...................................................................... 31 
10.2 
Identity of non-investigational products/Reference product ............................. 31 
10.3 
Manufacturing, packaging and labelling ............................................................. 31 
10.4 
Conditions for storage ............................................................................................ 31 
10.5 
Preparation and accountability............................................................................. 31 
10.6 
Treatment administration ..................................................................................... 32 
10.7 
Continuation of treatment with Investigational Product ................................... 32 

 
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10.8 
Treatment compliance ........................................................................................... 32 
10.9 
Return and destruction of investigational products............................................ 33 
11 
STUDY ASSESSMENTS ....................................................................................... 34 
11.1 
Recording of data ................................................................................................... 34 
11.2 
Demographics and other baseline characteristics ............................................... 34 
 
Informed consent .................................................................................................. 34 
 
Eligibility criteria.................................................................................................. 34 
 
Demographic information .................................................................................... 34 
 
Physical examination ............................................................................................ 34 
 
Weight and height................................................................................................. 35 
 
Medical/surgical history ....................................................................................... 35 
 
Prior and concomitant medication ........................................................................ 35 
 
HIV and Hepatitis B/C ......................................................................................... 35 
 
Pregnancy test ....................................................................................................... 35 
 
Urine drug screen ................................................................................................. 35 
 
Alcohol test ........................................................................................................... 35 
 
Baseline symptoms ............................................................................................... 36 
 
Assessment of snus consumption and smoking habits ......................................... 36 
 
Heaviness of smoking index ................................................................................. 36 
11.3 
Assessments related to primary endpoints........................................................... 36 
 
Pharmacokinetic sampling and analysis for primary endpoints ........................... 36 
11.4 
Assessments related to secondary endpoints ....................................................... 37 
 
Pharmacokinetic sampling and analysis for secondary endpoints ....................... 37 
 
Nicotine extraction from pouches ........................................................................ 37 
 
Products evaluation scale ..................................................................................... 37 
 
Modified cigarette evaluation questionnaire ........................................................ 37 
 
Products preference scale ..................................................................................... 37 
 
Adverse events...................................................................................................... 38 
 
Laboratory safety assessments ............................................................................. 42 
 
Vital signs ............................................................................................................. 43 
 
Electrocardiogram ................................................................................................ 43 
 
Assessment of cotinine levels for total exposure ................................................. 43 
11.5 
Appropriateness of measurements ....................................................................... 44 
12 
PROCEDURES FOR BIOLOGICAL SAMPLES .............................................. 45 
12.1 
Sample collection .................................................................................................... 45 
12.2 
Volume of blood ...................................................................................................... 45 
12.3 
Handling, storage and destruction of laboratory samples.................................. 45 
12.4 
Chain of custody of biological samples ................................................................. 45 
12.5 
Withdrawal of informed consent for donated biological samples ..................... 46 
13 
QUALITY MANAGEMENT, QUALITY ASSURANCE AND QUALITY 
CONTROL .............................................................................................................. 47 
13.1 
Quality management: critical process, system and data identification ............. 47 
13.2 
Quality assurance and quality control ................................................................. 47 
14 
ETHICAL AND REGULATORY REQUIREMENTS ...................................... 48 
14.1 
Ethical conduct of the study .................................................................................. 48 
14.2 
Ethics and regulatory review ................................................................................ 48 
14.3 
Subject information and consent .......................................................................... 48 

 
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14.4 
Subject data protection .......................................................................................... 48 
14.5 
Changes to the approved clinical study protocol................................................. 49 
14.6 
Audits and inspections ........................................................................................... 49 
14.7 
Insurance ................................................................................................................. 49 
15 
STUDY MANAGEMENT ..................................................................................... 50 
15.1 
Training of study site personnel ............................................................................ 50 
15.2 
Clinical monitoring ................................................................................................ 50 
15.3 
Source data documents .......................................................................................... 51 
15.4 
Study agreements ................................................................................................... 51 
15.5 
Study timetable and end of study.......................................................................... 51 
15.6 
Termination of the study ....................................................................................... 51 
15.7 
Reporting and publication ..................................................................................... 52 
 
Clinical study report ............................................................................................. 52 
 
Confidentiality and ownership of study data ........................................................ 52 
 
Publication ............................................................................................................ 52 
15.8 
Archiving ................................................................................................................. 52 
16 
DATA MANAGEMENT ....................................................................................... 53 
16.1 
The web-based eCRF ............................................................................................. 53 
16.2 
The entering of data into the eCRF ...................................................................... 53 
16.3 
The query process................................................................................................... 53 
16.4 
Audit trail ................................................................................................................ 54 
16.5 
External data .......................................................................................................... 54 
16.6 
Medical coding ........................................................................................................ 54 
16.7 
Database lock .......................................................................................................... 54 
17 
STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE . 55 
17.1 
General .................................................................................................................... 55 
17.2 
Determination of sample size ................................................................................ 55 
17.3 
Analysis data sets .................................................................................................... 55 
 
Full analysis set .................................................................................................... 55 
 
Safety analysis set................................................................................................. 55 
 
Per protocol set ..................................................................................................... 55 
 
Pharmacokinetic analysis set ................................................................................ 56 
17.4 
Description of study population ............................................................................ 56 
 
Demographics and baseline characteristics .......................................................... 56 
 
Medical/surgical history and prior/concomitant medication ................................ 56 
 
Treatment compliance .......................................................................................... 56 
 
Heaviness of smoking index ................................................................................. 56 
17.5 
Analysis of primary endpoints .............................................................................. 56 
 
Analysis of pharmacokinetics ............................................................................... 56 
17.6 
Analysis of secondary endpoints ........................................................................... 57 
 
Pharmacokinetics .................................................................................................. 57 
 
In vivo extracted amount of nicotine .................................................................... 57 
 
Products evaluation scale ..................................................................................... 58 
 
Modified cigarette evaluation questionnaire ........................................................ 58 
 
Products preference scale ..................................................................................... 58 
 
Adverse events...................................................................................................... 58 
 
Clinical laboratory analyses ................................................................................. 58 
 
Vital signs ............................................................................................................. 58 

 
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12-lead ECG ......................................................................................................... 59 
 
Total exposure (cotinine in plasma) ..................................................................... 59 
18 
REFERENCES ....................................................................................................... 60 
19 
SIGNATURES ........................................................................................................ 61 
19.1 
Principal Investigator statement ........................................................................... 61 
19.2 
Signature page (approval of the clinical study protocol) .................................... 62 
 
List of Tables 
Table 4.1-1 
Medical emergencies contact ........................................................................... 13 
Table 7.1-1 
Primary objective and endpoints ...................................................................... 18 
Table 7.2-1 
Secondary objectives and endpoints ................................................................ 18 
Table 8.1-1 
Overall schedule of events ............................................................................... 23 
Table 8.1-2 
Detailed schedule of events for Day 1, Day 2, Day 3, Day 4 and Day 5 ......... 24 
Table 10.6-1 
Investigational products – Instructions for use ............................................ 32 
Table 11.4-1 
Safety laboratory parameters ........................................................................ 42 
Table 12.2-1 
Estimated blood volumes ............................................................................. 45 
 
List of Figures 
Figure 8.1-1 
Overview of study design ................................................................................. 22 
 
 

 
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3 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation or term                   Explanation 
AE 
Adverse event 
ADR 
Adverse drug reaction 
ALT 
Alanine aminotransferase 
AST 
Aspartate aminotransferase 
ATC 
Anatomical therapeutic chemical  
AUC 
 
Area under the plasma concentration-time curve 
AUC0-90 
AUC from 0 to 90 minutes 
AUCinf 
AUC from 0 to infinity 
AUCt 
AUC from 0 to the time of the last sampling 
timepoint 
bpm 
Beats per minute (unit for pulse measurement) 
BMI 
Body mass index 
CC 
Conventional cigarette 
Clast 
Observed plasma concentration at the last sampling 
timepoint 
Cmax 
Maximum observed plasma concentration 
CSP 
Clinical study protocol 
CSR 
Clinical study report 
CTC 
Clinical Trial Consultants AB 
CV 
Coefficient of variation 
DMP 
Data management plan 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
EDC 
Electronic data capture 
EEA 
European Economic Area 
GCP 
Good clinical practice 
GDPR 
General data protection regulation 
Hb 
Haemoglobin 
HIV 
Human immunodeficiency virus 
ICF 
Informed consent form 
ICH 
International Council for Harmonisation of 
Technical Requirements for Pharmaceuticals for 
Human Use  

 
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IEC 
Independent ethics committee 
IME 
Important medical event 
IP 
Investigational product 
ISF 
Investigator site file 
LLOQ 
Lower limit of quantification 
MedDRA 
Medical dictionary for regulatory activities 
mmHg 
Millimetre mercury (unit for blood pressure 
measurements) 
NCA 
Non-compartmental analysis 
NGP 
Next generation products 
OND 
Oral nicotine delivery 
PII 
Personally Identifiable Information 
PK 
Pharmacokinetic 
PPS 
Per protocol analysis set 
PT 
Preferred term 
PV 
Pharmacovigilance 
QC 
Quality control 
RBC 
Red blood cell 
SADR 
Serious adverse drug reaction 
SAE 
Serious adverse event 
SAP 
Statistical analysis plan 
SD 
Standard deviation 
SDV 
Source data verification 
SOC 
System organ class 
SOP 
Standard operating procedures 
TMF 
Trial master file 
Tmax 
Time of occurrence of Cmax 
T½ 
Terminal elimination half-life 
WBC 
White blood cell 
WHO 
World Health Organisation 
WOCBP 
Women of childbearing potential 

 
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IP manufacturing, packaging, labelling 
Skruf Snus AB, 
Vinkelgatan 2-4 
576 33 Sävsjö, Sweden  
 
Electronic data capture (EDC) system 
provider:  
 
Viedoc Technologies AB 
S:t Persgatan 6 
SE-753 20 Uppsala, Sweden 
 
Signatures are provided in Section 19. 

 
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6 
INTRODUCTION 
6.1 
Background 
Smoking is a leading cause of numerous human disorders including lung cancer, chronic 
obstructive pulmonary disease, and atherosclerotic cardiovascular disease. Despite the well 
characterised health risks, smoking rates in adult populations worldwide remain at 15% to 
25%. In addition to methods of helping people quit, investigations are ongoing into the health 
benefits of reducing exposure to toxicants in people who continue to use tobacco. This is 
being done through the development of new tobacco and nicotine products, often referred to 
as next generation products (NGP). 
Tobacco-related health risks are assumed to be due to repeated and sustained exposure to a 
range of smoke toxicants. Smoke from conventional cigarettes (CC) is a complex and 
dynamic mixture of more than 5,600 identified chemical constituents, in both its particulate 
and vapour phases. Some of these chemicals have been identified as potential contributors to 
the harmful effects of cigarette smoke and can be evaluated by measuring the levels of these 
chemicals themselves, or their metabolites, in urine. 
Nicotine is primarily responsible for the addictive properties of cigarette smoking. Nicotine is 
rapidly absorbed into the bloodstream during cigarette smoking, from where it is rapidly 
distributed causing both systemic and central effects. In the central nervous system, nicotine 
acts at neuronal nicotinic receptors and this interaction may underpin its effects on mood and 
relaxation. The pharmacokinetic (PK) profile of nicotine during cigarette smoking is a rapid 
rise and fall in plasma nicotine concentrations. Correspondingly, the delivery of nicotine to 
the brain, and the consequent pleasurable effects experienced by the smoker, are also rapid. 
It is Imperial Brands’ aim to increasingly transition smokers to our NGP portfolio; products 
that are potentially less harmful than CC. Oral Nicotine Delivery (OND) is increasingly 
recognized as having the potential to reduce the risk of smoking. Oral Nicotine products also 
offer greater optionality in parts of the world where smoking or vaping is not permitted or 
where smokers prefer oral nicotine. At Imperial Brands we have added to our portfolio of 
NGP the ZoneX Oral Nicotine product which was launched in European markets in 2019.  
 Summary of non-clinical data 
All Imperial Brands snus and OND products (including ZoneX) undergo rigorous risk 
assessment by in-house professional toxicologists and external specialists to determine the 
suitability of ingredients and materials. As a responsible manufacturer we continuously 
review this approach. 
In vitro assays including the Ames test, neutral red uptake (NRU) and micronucleus assays, 
have been performed on smokeless tobacco products to investigate the cytotoxicity and 
genotoxicity of the product category, as described in the literature. The pre-clinical 
assessments have been performed on commercially available Swedish snus brands. 
The peer-reviewed research has demonstrated that extracts of smokeless tobacco products, 
including Swedish-style snus (such as Skruf snus), are markedly less mutagenic, clastogenic 
and cytotoxic than the particulate matter of cigarette smoke. It is generally reported that the 
genotoxicity and cytotoxicity of smokeless tobacco products is 10% or less active than cigarette 
smoke, when assessed in using similar testing methodology.  

 
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 Clinical experience 
This is the first clinical study of ZoneX products. 
6.2 
Study rationale 
This randomised, cross-over, open-label study is designed to primarily evaluate the relative 
bioavailability of nicotine delivery from oral tobacco-free nicotine delivery products, 
traditional snus and a conventional cigarette in male and female snus and cigarette consumers. 
6.3 
Risk/benefit assessment 
It may be considered problematic to expose research subjects to a nicotine delivery product, 
the properties of which are not yet fully known. However, all research subjects are required to 
be daily snus consumers since at least one year (with an average or above snus consumption) 
and dual users of cigarettes so the participants are well acquainted with, and used to, the 
effects of nicotine. 
As the nicotine delivery profile of a product is likely to be central to its acceptability among 
current tobacco users, it is reasonable to conduct formal clinical studies to assess this feature 
in more detail. 
All risks related to use of the study product or study procedures will be explained in detail to 
the subjects.   
Pregnant women are excluded from participation. 
The potential adverse effects of the study procedures are likely to be minor and/or clinically 
insignificant. 
Subjects will remain in the research clinic for at least 8 hours after the last use of the 
investigational products (IP) and will be closely monitored by medical staff. 
The Principal Investigator at the research clinic will ascertain that adequate facilities and 
procedures are available to handle emergency situations should they occur during the study. 
The medical staff at CTC have extensive experience from Phase I studies and there are 
adequate procedures in place to handle unexpected and expected adverse reactions in the 
study subjects.  
Besides the risks related to the IP as described above, there may also be risks related to the 
medical devices used in the study e.g. indwelling venous catheters. However, these are 
devices that are used in routine medical care and the risk associated with their use is 
considered low and ethically justifiable. Study specific evaluations and sampling procedures, 
like blood-pressure measurements using a blood pressure cuff and frequent blood-sampling, 
may cause transient discomfort but the risk is deemed to be low and ethically justifiable. 
Risk assessment with regards to the COVID-19 pandemic: 
Current recommendations from the authorities will be considered on a day-to-day basis. On-
going risk evaluation, assessment sessions with Sponsors, Investigators, CRO/vendor 
representative members to align on local restrictions, impact assessment, contingency plans 
and study-specific risk mitigation strategies will be made to safeguard the study conduct and 
the safety of the study subjects. This study is a short-term study including a healthy 
population. Hence, study participation is not expected to confer increased risks to the study 
subjects in terms of COVID-19 exposure. 
 

 
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7 
STUDY OBJECTIVES AND ENDPOINTS 
7.1 
Primary objective and endpoints 
Table 7.1-1 
Primary objective and endpoints 
Primary objective 
Primary endpoints 
Assessment 
To evaluate and compare the maximum 
plasma concentration (Cmax) and the area 
under the curve at the last timepoint measured 
(AUCt) of nicotine after the use of each 
product. 
Cmax and AUCt   
Pharmacokinetic 
sampling and analysis, 
(Refer to section 11.3.1) 
7.2 
Secondary objectives and endpoints 
Table 7.2-1 
Secondary objectives and endpoints 
Secondary objectives 
Secondary endpoints 
Assessment(s) 
To evaluate other pharmacokinetic 
parameters of nicotine after the use of each 
product 
 
AUC timepoint 0 to 90 
minutes (AUC0-90),  
AUC timepoint 0 to infinity 
(AUCinf),  
time to Cmax (Tmax),  
plasma concentration at last 
timepoint measured (Clast), 
terminal elimination half-
life (T1/2) 
Pharmacokinetic 
sampling and analysis, 
(Refer to section 11.3.1) 
To evaluate extracted dose of nicotine in used 
products 
 
The extracted dose of 
nicotine from each portion to 
evaluate the correlation 
between AUC and extracted 
dose of nicotine. 
Collection of pouches 
and analysis  
(Refer to section 11.4.2) 
To evaluate product perception and preference 
by use of subjective assessments 
 
Subjective smoking effects 
Product evaluation scale 
questionnaire (PES) 
(Refer to section 11.4.3) 
Modified cigarette 
evaluation questionnaire 
(MCEQ) (Refer to 
section 11.4.4) 
Products preference scale 
(PPS) (Refer to 
section 11.4.5) 
To evaluate the tolerability and safety of each 
of the products used 
 
Frequency, intensity and 
seriousness of adverse events 
(AEs) 
 
AE reporting and 
questioning 
(Refer to section 11.4.6) 

 
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Clinically significant 
changes in laboratory 
parameters, vital signs and 
ECG 
Blood sampling for 
clinical chemistry and 
hematology 
(Refer to section 11.4.7) 
Blood pressure and pulse 
(Refer to section 11.4.8) 
12-lead ECG  
(Refer to section 11.4.9) 
To evaluate the total nicotine exposure by 
measuring cotinine following single and ad 
lib use of each of the products. 
Assessment of total nicotine 
exposure following plasma 
cotinine levels 
(concentration and 
applicable calculated PK 
parameters) following 
controlled single use and ad 
lib use of IP 
Blood sampling for 
analysis of cotinine 
(Refer to section 11.4.10) 
 
 

 
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8 
STUDY DESIGN 
8.1 
Overall study design and schedule of events 
This will be a randomised cross-over, open-label, confinement study conducted in 24 male or 
female snus and cigarette consumers. The study will investigate 5 different nicotine 
containing products in a cross-over fashion. Cross-over in design, the study will incorporate 
pharmacokinetics evaluation, nicotine extraction evaluation, subjective questionnaire 
assessments as well as safety evaluation. 
During the study participation, subjects will come for 2 visits to the clinic, including a 5-day 
confinement period and finally a have an end-of-study telephone call within a week of 
product use. 
Visit 1 (Screening)  
Visit 1 will take place from Day -28 to Day -1 and will include an eligibility check, review of 
health status and assessment of snus and cigarette consuming habits, see Table 8.1-1 for 
details. Subjects will be provided with smoking cessation advice and contact information for a 
smoking cessation support service, should they request it. 
Subjects will be advised of the risks of using nicotine and referred to smoking/nicotine-use 
cessation support to quit if that is their intention. 
Visit 2 (In-clinic treatment period, Day -1 to Day 5) 
At Visit 2, subjects will be admitted to the clinic on the evening of Day -1 and will remain at 
the clinic until Day 5 for daily single IP use and PK, nicotine extraction, subjective 
questionnaire assessments and safety assessments. 
On the evening of Day -1, subjects will be undertaking baseline assessments for clinical 
laboratory profile, vital signs and ECG. Subjects are allowed to use their own snus product 
until 10pm on the evening of Day -1. At 10pm, the subjects’ own nicotine containing products 
will be collected by a member of the clinical team and returned upon completion of Day 5. 
On Day -1 the subjects will also undertake a familiarisation session of the study products and 
questionnaires. The clinical team will explain how the products will be used and the subjects 
will have the opportunity to see the product and packaging. An explanation of how the 
questionnaires will be administered to the subjects will be given. The familiarisation session 
does not include a product trial and all products used in the session will not be used in the 
clinical study but will be retained as demonstration samples for accountability purposes. 
In the morning of Day 1, after pre-use assessments and confirmation of eligibility, the 
subjects will be randomised and then administered a single pouch/single cigarette of the IP in 
the sequence to which they have been randomised. Oral nicotine IP will be used for 20 
minutes with standard use instructions. The cigarette will be smoked in approximately 5 
minutes with puffs taken at regular intervals approximately 30 seconds apart. PK sampling 
will be done pre-IP use and at 2, 5, 7, 15, 20, 30, 45, 60, 90 minutes, 2, 4, 6 and 8 hours post-
IP use start. Sampling for plasma cotinine levels will be taken pre-IP use and at 4, 8 and 12 
hours post-IP use start. Used pouches will be collected for analysis of nicotine extraction. 
Questionnaires will be administered to the subject at defined intervals throughout the day. 
Safety will be followed throughout the day. Subjects will be allowed to use the IP, to which 
they are assigned that day, ad lib after the 8-hour timepoint until 10 pm. 

 
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In the morning of Day 2, after pre-IP use assessments, the subjects will be administered a 
single pouch/single cigarette of the IP in the sequence to which they have been randomised. 
IP will be used for 20 minutes with standard use instructions. The cigarette will be smoked in 
approximately 5 minutes with puffs taken at regular intervals approximately 30 seconds apart. 
PK sampling will be done pre-IP use and at 2, 5, 7, 15, 20, 30, 45, 60, 90 minutes, 2, 4, 6 and 
8 hours post-IP use start. Sampling for plasma cotinine levels will be taken pre-IP use and at 
4, 8 and 12 hours post-IP use start. Used pouches will be collected for analysis of nicotine 
extraction. Questionnaires will be administered to the subject at defined intervals throughout 
the day. Safety will be followed throughout the day. Subjects will be allowed to use the IP, to 
which they are assigned that day, ad lib after the 8-hour timepoint until 10 pm. 
In the morning of Day 3, after pre-IP use assessments, the subjects will be administered a 
single pouch/single cigarette of the IP in the sequence to which they have been randomised. 
IP will be used for 20 minutes with standard use instructions. The cigarette will be smoked in 
approximately 5 minutes with puffs taken at regular intervals approximately 30 seconds apart.  
PK sampling will be done pre-IP use and at 2, 5, 7, 15, 20, 30, 45, 60, 90 minutes, 2, 4, 6 and 
8 hours post-IP use start. Sampling for plasma cotinine levels will be taken pre-IP use and at 
4, 8 and 12 hours post-IP use start. Used pouches will be collected for analysis of nicotine 
extraction. Questionnaires will be administered to the subject at defined intervals throughout 
the day. Safety will be followed throughout the day. Subjects will be allowed to use the IP, to 
which they are assigned that day, ad lib after the 8-hour timepoint until 10 pm. 
In the morning of Day 4, after pre-IP use assessments, the subjects will be administered a 
single pouch/single cigarette of the IP in the sequence to which they have been randomised. 
IP will be used for 20 minutes with standard use instructions. The cigarette will be smoked in 
approximately 5 minutes with puffs taken at regular intervals approximately 30 seconds apart.  
PK sampling will be done pre-IP use and at 2, 5, 7, 15, 20, 30, 45, 60, 90 minutes, 2, 4, 6 and 
8 hours post-IP use start. Sampling for plasma cotinine levels will be taken pre-IP use and at 
4, 8 and 12 hours post-IP use start. Used pouches will be collected for analysis of nicotine 
extraction. Questionnaires will be administered to the subject at defined intervals throughout 
the day. Safety will be followed throughout the day. Subjects will be allowed to use the IP, to 
which they are assigned that day, ad lib after the 8-hour timepoint until 10 pm. 
In the morning of Day 5, after pre-IP use assessments, the subjects will be administered a 
single pouch/single cigarette of the IP in the sequence to which they have been randomised. 
IP will be used for 30 minutes with standard use instructions. The cigarette will be smoked in 
approximately 5 minutes with puffs taken at regular intervals approximately 30 seconds apart. 
PK sampling will be done pre-IP use and at 2, 5, 7, 15, 20, 30, 45, 60, 90 minutes, 2, 4, 6 and 
8 hours post-IP use start. Sampling for plasma cotinine levels will be taken pre-IP use and at 
4 and 8 hours post-IP use start. Used pouches will be collected for analysis of nicotine 
extraction. Questionnaires will be administered to the subject at defined intervals throughout 
the day. Safety will be followed throughout the day. Subjects will leave the research clinic 
after completing all 8 h-assessments on Day 5. 
Visit 3 (End-of-Study phone call) 
A follow-up telephone call (Visit 3, end-of-study) will be made on Day 7 (±1) to follow-up on 
adverse events. 
Subjects will participate in the study for up to 35 days, including an up to 28-day screening 
period. 
An overview of the study design is shown in Figure 8.1-1.  

 
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8.2 
Rationale for study design 
The study will provide important safety and PK data to support the design of further studies. 
The time points for PK blood sampling were selected based on data obtained from previous 
non-clinical and clinical studies. 
A crossover design was chosen to yield a more efficient comparison of treatments than a 
parallel study design, i.e., fewer subjects are required since each subject will serve as its own 
control. 
A traditional snus with a nicotine strength similar to that of the investigational product was 
chosen as a comparator to achieve the best possible intra-subject comparison to OND 
products. 
The purpose of the cigarette comparator is twofold; first for Imperial to begin to understand 
more deeply the potential harm reduction potential of next generation products, such as OND; 
and also to evaluate the total nicotine exposure of OND against a cigarette, in this case in a 
single use situation and to inform on future studies in an ad-lib usage situation.  
Randomisation will be used to minimise bias in the assignment of subjects to a treatment 
sequence and to increase the likelihood that known and unknown subject attributes (e.g., 
demographic and baseline characteristics) are evenly balanced across treatment groups. 
 
 

 
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9 
STUDY POPULATION  
Prospective approval of protocol deviations to eligibility criteria, also known as protocol 
waivers or exemptions, is not permitted. 
9.1 
Recruitment 
The subjects will be recruited from CTC’s database of healthy volunteers and from 
advertising in media (including social media). 
9.2 
Screening and enrolment log 
Investigators must keep a record of all screened subjects even if they were not subsequently 
included in the study. This information is necessary to verify that subjects were selected 
without bias. The reason for screen failure should be stated for all subjects screened but not 
included. The reason for withdrawal should be stated for all subjects included but not 
completed. 
A screening number will be allocated to each subject in connection to the informed consent 
process at the Screening visit. The screening number is generated automatically in the 
electronic case report Form (eCRF). The screening number will allow identification of 
subjects irrespective of their possible eligibility for the study. 
Subjects included and randomised will be assigned a randomisation number (101, 102 etc.). 
If a subject cannot perform the first planned use of IP within 28 days after screening (i.e., the 
time interval between signing informed consent until first IP use) the subject should be 
rescreened before proceeding in the study. 
9.3 
Number of subjects 
Twenty Four subjects will be included in the study. Approximately 48 subjects will be 
screened to achieve a total of 24 randomised subjects. 
For replacements of subjects who discontinue from the study, see Section 9.8. 
9.4 
Inclusion criteria 
For inclusion in the study, subjects must fulfil the following criteria:  
1. Willing and able to give written informed consent for participation in the study.  
2. Male or female subject aged ≥19 years at the time of screening. 
3. Body Mass Index (BMI) ≥ 18.0 and ≤ 30.0 kg/m2. 
4. Clinically normal medical history, physical findings, vital signs, ECG and laboratory 
values at the time of screening, as judged by the Investigator. 
5. Dual user of snus and conventional cigarettes for ≥1 year, with a minimum weekly 
consumption of two or more snus cans and >5 cigarettes, and who is willing and able to 
use brands with nicotine content ≥1%. 

 
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9.5 
Exclusion criteria 
Subjects must not enter the study if any of the following exclusion criteria are fulfilled: 
1. History of any clinically significant disease or disorder which, in the opinion of the 
Investigator, may either put the subject at risk because of participation in the study, or 
influence the results or the subject’s ability to participate in the study. 
2. Any clinically significant illness, medical/surgical procedure or trauma within 4 weeks 
of the first use of IP. 
3. Any planned major surgery within the duration of the study. 
4. Any positive result on screening for serum hepatitis B surface antigen, hepatitis C 
antibody and Human Immunodeficiency Virus (HIV). 
5. After 10 minutes supine rest at the time of screening, any vital signs values outside the 
following ranges: 
• Systolic blood pressure <90 or >140 mmHg, or 
• Diastolic blood pressure <50 or >90 mmHg, or  
• Pulse <40 or >90 bpm 
6. Female subjects who are pregnant or who are currently breast feeding. 
7. History of severe allergy/hypersensitivity or ongoing allergy/hypersensitivity, as judged 
by the Investigator, or history of hypersensitivity to drugs with a similar chemical 
structure or class to nicotine. 
8. Planned treatment or treatment with another IP within 1 month or investigational drug 
within 3 months prior to Day -1. Subjects consented and screened but not dosed in 
previous phase I studies are not excluded. 
9. Positive screen for drugs of abuse or alcohol at screening or on admission to the 
research unit prior to use of the IP. 
10. History of alcohol abuse or excessive intake of alcohol, as judged by the Investigator. 
11. Presence or history of drug abuse, as judged by the Investigator. 
12. History of, or current use of, anabolic steroids, as judged by the Investigator.  
13. Excessive caffeine consumption defined by a daily intake of >5 cups of caffeine 
containing beverages. 
14. Plasma donation within one month of screening or blood donation (or corresponding 
blood loss) during the three months prior to screening. 
15. Subjects who intend to change their smoking habit or make a quit attempt within the 
next 3 months from the screening visit. 
16. Investigator considers the subject unlikely to comply with study procedures, restrictions 
and requirements. 
9.6 
Restrictions during the study 
The subjects must be willing to comply to the following restrictions during the entire study 
duration i.e., from screening to the end-of-study visit. 

 
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 General restrictions 
• Subjects shall abstain from snus and all other nicotine containing products from 10 pm 
the evening prior to the anticipated start of each IP use on Days 1 to 5.  
• Subjects shall abstain from smoking the last 24 hours before Day 1 (from 
approximately 8.00 am on Day -1) until the end of Visit 2 (on Day 5). 
• Use of other nicotine-containing products, than defined by this study protocol, is not 
allowed during the study from Day-1 until the end of Visit 2.  
• Subjects are not allowed to eat or drink or conduct any other mouth related procedure 
(e.g. tooth brushing) 30 minutes before IP use, during IP use and 30 minutes after the 
IP have been taken out. 
• Meals and Dietary Restrictions:  
Meals will be served while the study subjects are in the research clinic. Breakfast will 
be served approximately 1 hour prior to IP use. Lunch will be served 4 hours after start 
of each IP use. Snack, dinner and evening snack will be served approximately 7, 9 and 
11 hours post-IP use, respectively. Water is allowed ad libitum at the clinic except 
30 minutes before IP use until one hour after IP use on Days 1-5. 
• Alcohol: Consumption of alcohol is not allowed within 48 hours prior to the screening 
visit or Visit 2. Consumption of alcohol is not allowed during the subject’s stay at the 
clinic during Visit 2.  
• Drugs of abuse: Use of drugs of abuse is not allowed during the study (from the 
screening visit to the end-of-study visit). In addition to the urine drug testing described 
in Table 8.1-1, additional random testing can be performed at the clinic visits. 
• Coffee: Consumption of up to 5 cups of coffee per day will be allowed during the study 
(i.e., admission to the clinic on Day -1 to the end of Visit 2).  
• Xanthine or taurine containing products/beverages: Energy drinks (e.g. Red bull) are not 
allowed during the study from admission to the clinic on Day -1 until the end of Visit 2. 
• Exercise: The subjects must refrain from strenuous exercise (defined as greater than 
70% of the maximal pulse rate for one hour or more) during Visit 2.  
• Blood donation: The subjects must not donate blood or plasma during the study until 
three months after the final medical examination at Visit 2. 
• Participation in other clinical studies: Study subjects are not allowed to participate in 
any other interventional clinical study during the study period. 
 Prior and concomitant therapy 
Medications (prescribed or non-prescribed medication including antacids, analgesics, herbal 
remedies, vitamin supplements and minerals) considered necessary for the subject´s safety 
and wellbeing may be given at the discretion of the Investigator during the residential period. 
Following consultation with the Sponsor, the Investigator will determine whether or not the 
subject should continue in the study.  

 
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9.7 
Screen failures 
Screen failures are defined as subjects who consent to participate in the clinical study but do 
not fulfil all eligibility criteria and are not subsequently randomised in the study. A minimal 
set of screen failure information is required to ensure transparent reporting of screen failure 
subjects. Minimal information includes documentation of signed and dated informed consent 
form (ICF) and reason(s) for screening failure. 
Subjects who do not meet the criteria for participation in this study may be rescreened.  
Re-screening can be performed if any of the following were reasons for screening failure or 
non-randomisation (as judged by the Investigator): 
• Practical reasons.  
• Non-significant medical conditions (e.g. influenza, nasopharyngitis).  
• Reserve subject in a previous group 
• Plasma or blood donation outside allowed time windows. 
For subjects who are re-screened, a new screening number will be assigned and a new, signed 
ICF will be collected. 
9.8 
Subject withdrawal 
 General withdrawal criteria  
Subjects are free to discontinue their participation in the study at any time and for whatever 
reason without affecting their right to an appropriate follow-up investigation or their future 
care. If possible, the reason for withdrawal of consent should be documented. 
Subjects may be discontinued from the study at any time at the discretion of the Investigator. 
Reasons for discontinuation include:  
• Subject decision 
• Severe non-compliance to study protocol procedures, as judged by the Investigator 
and/or Sponsor 
• Subject is lost to follow-up.  
• Significant AEs posing a risk for the subject, as judged by the Investigator and/or 
Sponsor 
• Withdrawal of informed consent to the use of biological samples  
• Pregnancy 
• Death 
• Meeting of an exclusion criterion during the study, which, in the opinion of the 
Investigator, may pose a risk for the subject  

 
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 Procedures for discontinuation of a subject from the study 
A subject who prematurely discontinues participation in the study will always be asked about 
the reason(s) for discontinuation and the presence of any AEs. If a subject withdraws consent, 
the Investigator must ask the subject if he/she is willing, as soon as possible, to be assessed 
according to the procedures scheduled for the end-of-study visit. Any ongoing AEs will be 
followed as described in Section 11.4.6.12.  
The primary reason for discontinuation/early withdrawal must be specified in the eCRF and 
final product accountability must be performed. 
 Subject replacement 
Subjects who are prematurely withdrawn from the study for any reason may not be replaced 
during the course of the study. 
9.9 
Randomisation 
On Day 1, subjects will be randomised to one of 5 treatment sequences. The five different 
products are: 
A:  ZoneX #2, OND, white tobacco-free nicotine pouch, 5.8 mg nicotine/pouch 
B:  ZoneX #3, OND, white tobacco-free nicotine pouch, 10.1 mg nicotine/pouch 
C:  Skruf snus fresh slim white, 10.9 mg nicotine/pouch 
D:  
 
 
E:  Marlboro Gold, conventional cigarette, 0.8 mg nicotine/cigarette 
The 5 randomisation sequences are: 
Sequence 1: A:B:C:D:E 
Sequence 2: B:C:D:E:A 
Sequence 3: C:D:E:A:B 
Sequence 4: D:E:A:B:C 
Sequence 5: E:A:B:C:D 
 
 
 
A computer-generated randomisation list will be created by CTC using SAS Proc Plan, SAS 
Version 9.4. The randomisation list will contain subject number, sequence and treatment and 
will be kept by the randomiser until database lock. A copy of the randomisation list will be 
provided to the research clinic. 
9.10 Blinding 
This is an open-label study, i.e. the Investigator, study staff and subjects will know the type of 
IP to be received. 
 
 

 
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10 TREATMENTS  
The IPs, both test- and reference products are supplied by Imperial Tobacco. 
10.1 Identity of investigational products  
A:  ZoneX #2, OND, white tobacco-free nicotine pouch, 5.8 mg nicotine/pouch 
B:  ZoneX #3, OND, white tobacco-free nicotine pouch, 10.1 mg nicotine/pouch 
Comparators: 
C:  Skruf snus fresh slim white, 10.9 mg nicotine/pouch 
D:  
 
 
E: Marlboro Gold, conventional cigarette, 0.8 mg nicotine/cigarette 
10.2 Identity of non-investigational products/Reference product 
Not applicable. 
10.3 Manufacturing, packaging and labelling 
The IP, including the Skruf comparator product, is manufactured by Skruf Snus AB, Sävsjö, 
Sweden. 
The IP will be sent direct to the clinical site from the manufacturing plant.  The product will 
arrive in its market ready packaging (can) with the market label.  Each can of product contains 
24 oral nicotine pouches.  The IP will be shipped to the research clinic (CTC).  
The comparators 
 
and Marlboro Gold is commercially available and will be 
purchased by the research clinic. 
10.4 Conditions for storage 
The oral nicotine products will be stored in an access-controlled storage area at CTC, at 
refrigerated temperature (4-8°C). The cigarette comparator will be stored in an access-
controlled storage area at CTC, at room temperature (15-25°C). 
The temperature is recorded continuously by an automatic temperature control system. 
10.5 Preparation and accountability 
IP preparation for each individual subject and day will be done by trained personnel, i.e. a site 
pharmacist or a registered nurse, in a dedicated room at CTC according to the randomisation 
list. Each individual nicotine pouch will be weighed (in grams, with 2 decimals) before 
administration to the study subjects. The weight of each pouch will be recorded in the eCRF. 
Single units of IP for ad lib use will be handed out by the study nurses upon request from the 
subjects (see section 10.6). 
CTC and the Investigator will maintain a Storage and Accountability Log as well as a Drug 
Dispensing Log detailing the dates and quantities of study product received, prepared for and 
used by each subject and IP returned or destroyed at the end of the study. No IP will be 

 
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10.9 Return and destruction of investigational products 
Any unused study product and all empty containers will be returned to the sponsor or 
destroyed at the site upon confirmation from the Sponsor. The Monitor will perform final IP 
accountability reconciliation at the study end to verify that all unused IP is adequately 
returned/destroyed and documented. 
 

 
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11 STUDY ASSESSMENTS 
The study assessments are described in the sections below and the timing of these assessments 
are described in overview and in detail in the schedule of events (Table 8.1-1). 
11.1 Recording of data 
The Principal Investigator will provide the Sponsor with all data produced during the study 
from the scheduled study assessments. He/she ensures the accuracy, completeness, legibility, 
and timeliness of the data reported to Sponsor in the eCRF and in all required reports. 
It is important that PK blood sampling occurs as close as possible to scheduled time. In order 
to achieve this, the timing priority order at a particular time point is: 
1. IP pouch collection 
2. Blood samples for PK 
3. Questionnaires (PES before MCEQ) 
4. Standard 12-lead ECG 
5. Vital signs 
6. Safety laboratory samples 
Time points for PK blood sampling, clinical laboratory samples, ECGs, vital signs and 
questionnaires are outlined in the schedule of events (Table 8.1-1 and Table 8.1-2). 
Information on time windows for PK sampling, refer to Section 11.3.1. 
11.2 Demographics and other baseline characteristics 
 Informed consent 
Signed informed consent must be obtained before any screening procedures are initiated. The 
informed consent procedure is further described in Section 14.3. 
 Eligibility criteria 
Eligibility criteria should be checked during screening and verified before first IP use. The 
criteria are specified in Sections 9.4 and 9.5. 
 Demographic information 
The following demographic data will be recorded: gender, age, ethnicity and race. 
 Physical examination 
A physical examination will include general appearance including skin, auscultation of lungs 
and heart, abdomen (liver and spleen palpation). 
Any abnormalities will be specified and documented as clinically significant (CS) or not 
clinically significant (NCS).  

 
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 Weight and height 
Weight and height will be measured without shoes. BMI will be calculated, with one decimal, 
from the height and weight recorded. 
 Medical/surgical history  
Medical/surgical history will be obtained by subject interview in order to verify that the 
eligibility criteria are met. 
The medical/surgical history should include all relevant diseases and operations within 
2 weeks prior to screening as judged by the Investigator.  
 Prior and concomitant medication 
Prior medications taken within 2 weeks will be obtained by subject interview in order to 
verify that the eligibility criteria are met (see also Section 9.6.2). 
Medications are classified as prior if the stop date was before or on the day of the first IP use 
(pre-IP use) and as concomitant if ongoing on the day of the first IP use, stopped after the first 
IP use or started after the first IP use. To distinguish between prior and concomitant 
medications on Day 1 (i.e. the first IP use day), the start time of any newly introduced 
medication or the stop time of any previously ongoing medication must be recorded in the 
eCRF.  
Any use of concomitant medication from screening until the end-of-study visit must be 
documented appropriately in the subject’s eCRF. Relevant information (i.e. name of 
medication, dose, dose form, unit, route, frequency, start and stop dates, reason for use) must 
be recorded. All changes in medication should be noted in the eCRF. 
 HIV and Hepatitis B/C 
Subjects will be tested for HIV-1 and HIV-2 antibodies and HIV-1 p24 antigen, hepatitis B 
virus surface antigen and hepatitis C virus antibodies prior to inclusion into the study. Any 
positive result will exclude the subject from participating in the study. 
 Pregnancy test 
All WOCBP will do a pregnancy test (urine dipstick) at screening and at visits specified in 
Table 8.1-1. 
 Urine drug screen 
Urine will be screened for drugs of abuse at time points outlined in the schedule of events 
(Table 8.1-1) using the AlereTM Drug Screen Test Panel. Additional random tests can be 
performed during the study period. 
 Alcohol test 
An alcohol test will be performed at time points outlined in the schedule of events 
(Table 8.1-1). Additional random tests can be performed during the study period. 

 
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 Baseline symptoms  
A baseline symptom is defined as an event that occurs between the subject’s signing of the ICF 
until the start of the first IP use (i.e. an event that occurs during the screening period). Such 
events are not AEs and will be recorded as baseline symptoms in the Medical History Log in 
the eCRF. 
 Assessment of snus consumption and smoking habits 
At the screening visit, subject will be asked about their snus and smoking habits;  
“Which snus product is your usual choice?”  
“Which strength does the product have?” (in mg/g) 
“How many portions do you use per day?” 
“Which cigarette is your usual choice?”  
“Which strength does the product have?”  
“How many cigarettes do you smoke per day?” 
Answers will be collected in the eCRF.  
 Heaviness of smoking index 
At Day -1 subjects will answer the HSI by answering the 2 questions:  
“On the days that you smoke, how soon after you wake up do you have your first cigarette?” 
“How many cigarettes do you typically smoke per day?  
Answers will be collected in the eCRF.  
11.3 Assessments related to primary endpoints 
 Pharmacokinetic sampling and analysis for primary endpoints 
Venous blood samples (approximately 4 mL/sample) for the determination of plasma 
concentrations of nicotine after use of the IP, will be collected through an indwelling venous 
catheter at the pre-specified time-points (Table 8.1-2). 
Pre-IP use sampling may be performed within 5 minutes prior to IP use on Days 1-5, 
respectively. 
The following time windows will apply for the PK sampling post-IP use: 
± 1 minute for time-points up to 30 minutes after start of IP use. 
± 2 minutes for time-points up to 90 minutes after start of IP use. 
± 5 minutes for time-points up to 8 hours after start of IP use. 
The actual time of collection of each sample will be recorded in the eCRF. 
The blood samples will be collected in pre-labelled tubes. All the collected blood samples will 
be centrifuged to separate plasma. The separated plasma from each blood sample will be 
divided into 2 aliquots in pre-labelled cryotubes and frozen at -20°C. 
Plasma samples for determination of plasma concentrations of nicotine will be analysed by 
Lablytica AB by means of a validated using LC-MS/MS method. Samples from all evaluable 
subjects will be analysed. 

 
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11.4 Assessments related to secondary endpoints 
 Pharmacokinetic sampling and analysis for secondary endpoints 
Refer to Section 11.3.1. 
 Nicotine extraction and flavour analysis from pouches 
The individual nicotine pouch given in the morning and the first pouch for ab lib-use will be 
weighed (in grams, with 2 decimals) before administration to the study subjects. The weight 
of each pouch will be recorded in the eCRF. 
Used pouches will be collected after 20 minutes (+/- 1 minute) of use for the determination of 
residual nicotine in the IPs (morning puch) and flavour analysis (ad lib-pouch). After the 20-
minute exposure period, each pouch will be collected into a labelled poly bag, sealed and 
frozen. The label should have study number, day number, subject ID and product ID. 
All the collected pouches will be frozen immediately at -20°C. Pouches for extraction of 
nicotine and flavour analysis will be analysed by Reemtsma Labs, Hamburg. 
 Products evaluation scale 
The subject will self-assess their experience of product effect using the PES at timepoints 
detailed in Table 8.1-2.  
The rating for each question will be done using a 100 mm VAS scale with the anchor points 
0 mm (= Not at all/no urge) and 100 mm (= extremely/extreme urge) printed on paper. 
The self-assessment for each question at each time point (in mm’s) will be entered in the 
eCRF by the study personnel. 
 Modified cigarette evaluation questionnaire 
The subject will self-assess their experience of cigarette product effect using the MCEQ 
(12 sub-questions) at timepoints detailed in Table 8.1-2. This questionnaire will only be 
administered after use of the cigarette product. 
Each sub-question about how the study product made the subject feel will be assessed on 
paper on a 7-grade scale (1- not at all, 2- very little, 3-a little, 4-moderately, 5-a lot, 6-quite a 
lot, 7-extremely).  
The score for each sub-question at each time point will be entered in the eCRF by the study 
personnel. 
 Products preference scale 
The subject will self-assess their product preference using the PPS (2 sub-questions) at 
timepoints detailed in Table 8.1-2. 
The sub-questions: “Please rate the 3 pouch products in order of preference.” and “Please rate 
your use of a cigarette vs use of pouch.” (1- prefer cigarette, 2- no preference, 3-prefer pouch) 
will be assessed at the end of Day 5. 
The answer for each sub-question at each time point will be entered in the eCRF by the study 
personnel. 

 
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 Adverse events 
In this study, the IP is a nicotine product and not an investigational medicinal product. 
However, the procedures for monitoring, collecting and reporting of AEs will be the same as 
for an investigational medicinal product, as far as possible. The Principal Investigator is 
responsible for ensuring that all medical staff involved in the study are familiar with the 
content of this section and the content of the CTC standard operating procedures (SOPs) 
regarding emergencies and Phase I studies. 
11.4.6.1 Definition of adverse event  
An AE is defined as any untoward medical occurrence in a subject administered an IP and 
which does not necessarily have a causal relationship with this IP. An AE can therefore be 
any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, 
or disease temporally associated with the use of an IP, whether or not considered related to 
the IP. 
11.4.6.2 Definition of serious adverse event  
An SAE is any AE which: 
• results in death 
• is life-threatening (this refers to a reaction in which the subject was at risk of death 
at the time of the reaction; it does not refer to a reaction that hypothetically might 
had led to death if the reaction was more severe) 
• requires in-patient hospitalisation or prolongation of existing hospitalisation 
• results in persistent or significant disability/incapacity 
• is a congenital anomaly/birth defect 
• is an important medical event (IME) (this refers to a reaction that may not be 
immediately life-threatening or result in death or hospitalisation, but may jeopardise 
the subject or may require intervention to prevent any of the other outcomes defined 
above) 
Examples of IMEs are intensive treatment in an emergency room for allergic bronchospasm 
or blood dyscrasias, convulsions that do not result in hospitalisation, development of drug 
dependency, and drug abuse. 
Planned hospitalisations or surgical interventions for a condition that existed before the 
subject signed the ICF and that did not change in intensity are not SAEs. 
If there is any doubt as to whether an AE meets the definition of an SAE, a conservative 
viewpoint must be taken, and the AE must be reported as an SAE. 
11.4.6.3 Definition of adverse drug reaction 
The term ADR is to be used whenever either the Investigator or Sponsor or designee assessed 
the AE as at least possibly related to the IP. 

 
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11.4.6.4 Time period and frequency for collecting adverse events 
All AEs (including SAEs) will be collected from the start of IP use until the end-of-study 
visit. 
Any AE with start date on the day of the first IP use must be recorded with start time. 
At the end-of-study visit, information on new AEs or SAEs, if any, and stop dates for ongoing 
events must be recorded as applicable. 
Investigators are not obligated to actively seek AEs or SAEs after conclusion of the study 
participation. However, if the Investigator learns of any SAE, including a death, at any time 
after a participant has been discharged from the study, and he/she considers the event to be 
reasonably related to the study intervention or study participation, the Investigator must 
promptly notify the Sponsor. 
11.4.6.5 Assessment of intensity 
The intensity of each AE is to be graded by the Investigator. The intensity grades are defined 
as follows:  
Mild 
The event is usually transient and requires minimal treatment or therapeutic 
intervention. The event does not generally interfere with usual activities of 
daily living. 
Moderate 
The event is usually alleviated with additional specific therapeutic 
intervention. The event interferes with usual activities of daily living, causing 
discomfort but poses no significant of permanent risk or harm to the subject. 
Severe 
The event interrupts usual activities of daily living, or significantly affects 
clinical status, or may require intensive therapeutic intervention.  
11.4.6.6  
Assessment of causal relationship 
The Investigator must assess the causal relationship between an AE and the IP using the 
definitions below and record it the AE Log of the eCRF: 
Probable 
The event has a strong temporal relationship to the IP or recurs on re-
challenge, and another aetiology is unlikely or significantly less likely. 
Possible 
The event has a suggestive temporal relationship to the IP, and an alternative 
aetiology is equally or less likely. 
Unlikely 
The event has no temporal relationship to the IP or is due to 
underlying/concurrent illness or effect of another drug (that is, there is no 
causal relationship between the IP and the event). 
 
An AE is considered causally related to the use of the IP when the causality 
assessment is probable or possible. 
11.4.6.7 Assessment of outcome 
The Investigator must assess the outcome of an AE using the definitions below and record 
it on the AE Log of the eCRF: 

 
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Recovered/resolved 
The subject has recovered completely, and no symptoms remain. 
Recovering/resolving  The subject’s condition is improving, but symptoms still remain. 
Recovered/resolved 
with sequelae 
The subject has recovered, but some symptoms remain (for 
example, the subject had a stroke and is functioning normally but 
has some motor impairment). 
Not recovered/not 
resolved 
The subject’s condition has not improved and the symptoms are 
unchanged (for example, an atrial fibrillation has become chronic). 
Fatal 
 
Unknown 
 
11.4.6.8 Reporting of action taken with study treatment 
The Investigator must report the action taken with study product using the definitions below 
and record it on the AE Log of the eCRF: 
Dose increased   
Dose not changed 
Dose rate reduced 
Dose reduced 
Drug interrupted 
Drug withdrawn 
Not applicable 
Unknown 
11.4.6.9 Collecting adverse events 
AEs identified using any of the following methods will be recorded: 
• AEs spontaneously reported by the subject 
• AEs observed by the Investigator or medical personnel 
• AEs elicited based on non-leading questions from the Investigator or medical 
personnel 
11.4.6.10 Recording adverse events 
AEs must be recorded in the AE Log of the eCRF. The Investigator must provide 
information on the AE, preferably with a diagnosis or at least with signs and symptoms; 
start and stop dates, start and stop time; intensity; causal relationship to IP; action taken, 
and outcome. 
If the AE is serious, this must be indicated in the eCRF.  
AEs, including out-of-range clinically significant clinical safety laboratory values, must be 
recorded individually, except when considered manifestations of the same medical condition 
or disease state; in such cases, they must be recorded under a single diagnosis. 

 
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11.4.6.11  Reporting of serious adverse events  
SAE reporting should be performed by the Investigator within 24 hours of awareness via the 
eCRF. All available information regarding the SAE should be entered in the eCRF SAE form 
(i.e. term, intensity, causality, outcome, SAE criteria, action taken, narrative including rational 
for causality assessment) for the specific subject. By saving the event as “serious” in the 
eCRF and once the Investigator has signed-off of the event, an e-mail alert is automatically 
sent to predefined recipients to highlight that an SAE has been registered. The same 
information is automatically sent to sae@ctc-ab.se. 
If the SAE report in the eCRF is updated and signed by the Investigator, a new e-mail alert 
will be sent. 
In case the eCRF cannot be accessed, the SAE should be reported by manual completion of 
the paper SAE Form, provided in the Investigator Site File (ISF). The completed, signed and 
dated paper SAE Form should, within 24 hours, be scanned and e-mailed to:  
Cornelia Lif-Tiberg, MD, Medical Monitor 
Phone: +46 (0)73 978 94 45 
E-mail: cornelia-lif-tiberg@ctc-ab.se  
A copy of the paper SAE form must also be e-mailed to CTC at: sae@ctc-ab.se. 
The study site should notify the site Monitor via phone or e-mail about the submission of 
the SAE report. As soon as the site personnel have access to the eCRF, the SAE should be 
reported electronically as well. 
11.4.6.12 Treatment and follow-up of adverse events 
Subjects with AEs that occur during the study must be treated according to daily clinical 
practice at the discretion of the Investigator. 
AEs must be followed up until resolution or to the end-of-study visit, whichever comes first. 
At the end-of-study visit, information on new AEs, if any, and stop dates for previously 
reported AEs must be recorded (if known). AEs assessed as stable by the Investigator at the 
end-of-study visit will not have to be followed up until resolution. 
It is the responsibility of the Investigator to follow up on all SAEs until the subject has 
recovered, stabilised, or recovered with sequelae, and to report to the Sponsor all relevant new 
information using the same procedures and timelines as those for the initial report. Relevant 
information includes discharge summaries, autopsy reports, and medical consultation. 
11.4.6.13 Procedures in case of pregnancy 
In case of pregnancy or suspicion of possible pregnancy of any female subjects, the use of IP 
must be stopped immediately, and the subject discontinued from participation in the study. 
Pregnancy itself is not regarded as an AE unless there is a suspicion that the IP may have 
interfered with the effectiveness of the contraceptive medication. However, the outcome of all 
pregnancies (spontaneous miscarriage, elective termination, normal birth or congenital 
abnormality) must be followed up and documented even after the subject was discontinued 
from the study. 

 
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All events of congenital abnormalities/birth defects are SAEs. Spontaneous miscarriages 
should also be reported and handled as AEs. All outcomes of pregnancy must be reported to 
the Sponsor and the Principal Investigator on the pregnancy outcomes report form. 
11.4.6.14 Treatment of overdose 
An overdose is a dose in excess of the dose specified for each cohort in this CSP. 
Over-dosing is not likely to occur in this study since all IP will be administered by site 
personnel under medical surveillance. In cases of accidental overdose, standard supportive 
measures should be adopted as required. 
An overdose should be documented as follows:  
• An overdose with associated AE is recorded as the AE diagnosis/symptoms in the AE 
Log of the eCRF.  
• 
An overdose without associated symptoms is only reported in the subject’s medical 
records. 
No known antidote is available. 
 Laboratory safety assessments 
Blood samples for analysis of clinical chemistry and haematology will be collected through 
venepuncture or an indwelling venous catheter and sent to the certified clinical chemistry 
laboratory at Uppsala University Hospital and analysed by routine analytical methods.  
Urine analysis will be performed at the research clinic using dip sticks. 
The safety laboratory parameters are defined in Table 11.4-1 and will be assessed at time-
points detailed in Table 8.1-1. 
Any lab values outside the normal ranges will be judged as not clinically significant (NCS) or 
clinically significant (CS). The assessment will be recorded in the eCRF. Abnormal values 
assessed by the Investigator as clinically significant will be reported as AEs. If an abnormal 
value is associated with corresponding clinical signs or symptoms, the sign/symptom should 
be reported as the AE. 
Subjects will be tested for ongoing SARS-CoV-2 infection as a part of the laboratory panel on 
Day 5 or upon development of suspected COVID-19-symptoms during the stay at the research 
clinic. Testing will be performed using a routine qPCR method at the local hospital 
laboratory. Any positive result on testing on Day 5 will exclude the subjects from the analysis 
of nicotine extraction and flavour analysis due to current procedures at the analysing 
laboratory with regards to COVID-19. 
Table 11.4-1 Safety laboratory parameters 
Category 
Parameter 
Clinical chemistry 
Alanine aminotransferase (ALT) 
Aspartate aminotransferase (AST) 
Creatinine  
Glucose (non-fasting) 
Haematology 
Haematocrit 
Haemoglobin (Hb) 

 
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Category 
Parameter 
Platelet count 
Red blood cell (RBC) count 
White blood cell (WBC) count 
Urinalysis (dip stick) 
Erythrocytes 
Glucose 
Ketones 
Leucocytes 
Nitrite 
pH 
Protein 
Specific gravity 
Urobilinogen 
Pregnancy test  
Urine pregnancy test (dipstick) 
SARS-COV-2 qPCR 
testing (at Day 5 only or 
upon suspicion of 
COVID-19 symptoms) 
Detection of SARS-CoV-2 virus RNA 
 Vital signs 
Systolic and diastolic blood pressure (BP) and pulse will be measured in supine position after 
10 minutes of rest. 
Any vital signs outside the normal ranges will be judged as not clinically significant (NCS) or 
clinically significant (CS). The assessment will be recorded in the eCRF. Post-IP vital signs 
judged as “abnormal, clinically significant” by the Investigator will be reported as AEs. 
 Electrocardiogram 
Single 12-lead ECG will be recorded in supine position after 10 minutes of rest using an ECG 
machine. HR and PR, QRS, QT and QTcF intervals will be recorded.  
Safety ECGs will be reviewed and interpreted on-site by the Investigator. 
Any abnormalities will be specified and documented as clinically significant or not clinically 
significant. Abnormal post-IP use findings assessed by the Investigator as clinically 
significant will be reported as AEs. 
 Assessment of cotinine levels for total exposure 
Venous blood samples (approximately 4 mL/sample) for the determination of plasma 
concentrations of cotinine after use of the IP, will be collected through an indwelling venous 
catheter at the pre-specified time-points (Table 8.1-2). 
Pre-IP use sampling may be performed within 5 minutes prior to IP use on Days 1-5, 
respectively. 
The following time windows will apply for the cotinine sampling post-IP use: 
± 5 minutes for time-points up to 24 hours after start of IP use. 

 
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The actual time of collection of each sample will be recorded in the eCRF. 
Samples will be handled accoridng to the separate laboratory instructions. 
11.5 Appropriateness of measurements 
All methods used for safety assessments are commonly used in standard medical care and in 
Phase I clinical studies. Non-compartmental analysis of PK parameters is standard for Phase I 
clinical studies. 
 

 
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12 PROCEDURES FOR BIOLOGICAL SAMPLES 
12.1 Sample collection  
The sample collection procedure for PK analysis is described in Section 11.3.1. 
Safety laboratory samples are collected according to standard procedures. 
12.2 Volume of blood 
The anticipated volume of blood samples collected during the study from each subject will 
not exceed 450 mL (i.e., less than the volume drawn during a regular blood donation). 
Estimated blood volumes to be collected are presented in Table 12.2-1. 
Table 12.2-1 Estimated blood volumes 
Category 
Estimated number 
of sampling 
occasions 
Estimated 
volume per 
occasion 
Estimated 
total 
volume 
Clinical chemistry, hematology 
3 
20 mL 
60 mL 
HIV, Hepatitis B/C 
1 
10 mL 
10 mL 
PK sampling 
70 
4 mL 
280 mL 
Cotinine samples 
19 
4 ml 
76 mL 
Total: 
 
 
426 mL 
12.3 Handling, storage and destruction of laboratory samples 
All biological samples will be registered in a biobank at CTC (893).  
Any remains from the safety laboratory samples will be disposed of after analyses.  
The samples for analyses of PK parameters will be stored at <-20°C until analysed. The 
samples will be disposed of after the CSR has been finalised. 
All plasma samples transferred to the Sponsor’s biobank will, if not used, be disposed of after 
10 years. 
12.4 Chain of custody of biological samples 
A full chain of custody is maintained for all samples throughout their lifecycle.  
CTC keeps full traceability of collected biological samples from the subjects while in storage 
at the research clinic until shipment and keeps documentation of receipt of arrival.  
The sample receiver (the analytical laboratory) keeps full traceability of the samples while in 
their storage and during use until used or disposed of.  
The Sponsor keeps oversight of the entire life cycle through internal procedures, monitoring 
of study sites and auditing of external laboratory providers.  

 
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12.5 Withdrawal of informed consent for donated biological samples 
If a subject withdraws consent to the use of biological samples donated, the samples will be 
disposed of /destroyed, if not already analysed and documented.  
The Principal Investigator will ensure that:  
• Subject withdrawal of informed consent is notified immediately to Sponsor.  
• Biological samples from the subject, if stored at the research clinic, are immediately 
identified, disposed of/destroyed and the action is documented.  
The Sponsor has to ensure that the laboratory(ies) holding the samples is/are informed about 
the withdrawn consent immediately and that samples are disposed of/destroyed or returned to 
the research clinic and the action is documented. 
 
 

 
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13 QUALITY MANAGEMENT, QUALITY ASSURANCE AND QUALITY 
CONTROL 
13.1 Quality management: critical process, system and data identification 
During CSP development, the Sponsor will identify those processes, systems (facilities, 
computerised systems) and data that are critical to ensure human subject protection and the 
reliability of trial results according to applicable SOPs and International Council for 
Harmonisation (ICH) E6 R2. 
Identified risks, including risks associated with the COVID-19 (Coronavirus) pandemic, will 
be categorised separately from the CSP. 
Sponsor oversight responsibilities, such as monitoring, adverse event reporting, 
safety  monitoring, changes in investigators and key study team staff and quality assurance 
activities may need to be reassessed in relation to the COVID-19 pandemic and temporary, 
alternative proportionate mechanisms of oversight may be required. 
13.2 Quality assurance and quality control 
The Sponsor is responsible for implementing and maintaining quality assurance (QA) and 
quality control (QC) systems with written SOPs with regards to management of identified 
risks, CSP compliance, good clinical practice (GCP) compliance and applicable regulatory 
requirements.  
The Sponsor is responsible for securing agreements with involved subcontractors and to 
perform regular subcontractor oversight to ensure CSP compliance, GCP compliance and 
compliance with applicable regulatory requirements.  
The Sponsor is responsible for implementing a risk-based validated electronic data capture 
system and maintain SOPs for the whole life cycle of the system. 
QC should be applied to each stage of data handling to ensure that all data are reliable and 
have been processed correctly. 
The Sponsor has delegated the responsibilities outlined above to CTC whilst maintaining 
overall study oversight. 
 
 

 
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14 ETHICAL AND REGULATORY REQUIREMENTS  
14.1 Ethical conduct of the study 
The study will be performed in accordance with ethical principles that have their origin in the 
Declaration of Helsinki [1] and are consistent with ICH/GCP E6 (R2), EU Clinical Trials 
Directive, and applicable local regulatory requirements. 
14.2 Ethics and regulatory review 
The Principal Investigator is responsible for submission of the CSP, the subject information 
and ICF, any other written information to be provided to the subjects and any advertisements 
used for recruitment of subjects to applicable IEC for approval.  
Approval must be obtained in writing from the IEC before the first subject can be recruited. 
The Sponsor will provide the IEC and Principal Investigators with relevant safety information 
during the course of the study in accordance with local regulations and requirements. 
14.3 Subject information and consent 
It is the responsibility of the Investigator or an authorised associate to give each potential 
study subject adequate verbal and written information before any study specific assessments 
are performed. 
The information will include the objectives and the procedures of the study as well as any 
risks or inconvenience involved. It will be emphasised that participation in the study is 
voluntary and that the subject may withdraw from participation at any time and for any 
reason, without any prejudice. All subjects will be given the opportunity to ask questions 
about the study and will be given sufficient time to consider participation before signing the 
ICF. 
Before performing any study-related procedures the ICF must be signed and personally dated 
by the subject and by the Investigator. A copy of the subject information including the signed 
ICF will be provided to the subject. 
Documentation of the discussion and the date of informed consent must be recorded in the 
source documentation and in the eCRF. The subject information sheet and the signed ICF 
should be filed by the Investigator for possible future audits and/or inspections.  
The final approved version of the subject information and ICF must not be changed without 
approval from the Sponsor and the applicable IEC.  
14.4 Subject data protection 
The ICF includes information that data will be recorded, collected and processed and may be 
transferred to European Economic Area (EEA) or non-EEA countries. In accordance with the 
European Union Data Protection Directive (95/46/EC) and General Data protection 
Regulation (GDPR), the data will not identify any persons taking part in the study. 
The potential study subject should be informed that by signing the ICF he/she approves that 
authorised representatives from Sponsor and CTC, the concerned IEC and CA have direct 

 
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access to his/her medical records for verification of clinical study procedures. For further 
details on the subject information and ICF process, refer to Section 14.3. 
The subject has the right to request access to his/her personal data and the right to request 
rectification of any data that is not correct and/or complete in accordance with the European 
Union Data Protection Directive (95/46/EC) and the request will be raised to the Principal 
Investigator.  
The Investigator must file a Subject Identification List which includes sufficient information 
to link records, i.e. the eCRF and clinical records. This list should be preserved for possible 
future inspections/audits but must not be made available to the Sponsor except for monitoring 
or auditing purposes. 
Personal data that are collected in the study such as health information and ethnicity are 
considered as sensitive personal data. This data will be pseudoanonymised, i.e. personally 
identifiable information (PII) will be removed and replaced by a unique subject ID and will be 
processed by the Sponsor and other involved parties during the study. After the study end, 
only anonymised data, i.e. aggregated data sets, can be used.  
For this study, the Sponsor is the data controller of all data processed during the study (e.g. 
Trial Master File [TMF], study reports) and CTC AB is the data processor. Any 
subcontractors used in the study, are also data processors.  
For data that are processed at the clinic(s) (e.g. medical records and ISF), CTC AB is the data 
controller.  
14.5 Changes to the approved clinical study protocol  
Any proposed change to the approved final CSP (including appendices) will be documented 
in a written and numbered clinical protocol amendment. All substantial amendments to the 
protocol must be approved by the appropriate IEC before implementation according to 
applicable regulations. 
14.6 Audits and inspections 
Authorised representatives of Sponsor, or an IEC may perform audits or inspections at the 
research clinic, including source data verification (SDV). The purpose of an audit or 
inspection is to systematically and independently examine all study-related activities and 
documents, to determine whether these activities were conducted, and data were recorded, 
analysed, and accurately reported according to the protocol, ICH-GCP guidelines and any 
applicable regulatory requirements. The Investigator will contact the Sponsor immediately if 
contacted about an inspection at the site. 
14.7 Insurance 
Subjects will be covered under the Sponsor’s liability insurance policy. The certificate of 
insurance and an information leaflet containing essential information about the insurance 
coverage can be provided upon request. The participating subjects are also protected in 
accordance with national regulations, as applicable. CTC has a company insurance covering 
services performed by CTC. 
 
 

 
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15 STUDY MANAGEMENT 
15.1 Training of study site personnel 
Before enrolment of the first study subject a Sponsor representative or delegate will perform a 
study initiation visit at the research site. The requirements of the CSP and related documents 
will be reviewed and discussed and the investigational staff will be trained in any study 
specific procedures and system(s) utilised. 
It is the responsibility of the Investigator to ensure that all personnel involved in the study are 
fully informed of all relevant aspects of the study and have a detailed knowledge of and 
training in the procedures that are to be executed by them. Any new information of relevance 
to the performance of this study must be forwarded to the staff involved in a timely manner. 
The Investigator will keep a list of all personnel involved in the study together with their 
function and study related duties delegated. A Curriculum Vitae will be available for all staff 
to whom study-specific duties are delegated. 
15.2 Clinical monitoring  
The Sponsor is responsible for securing agreement from all involved parties to ensure direct 
access to all study related sites, source data/documents, and reports for the purpose of 
monitoring and auditing by the Sponsor, and inspection by domestic and foreign regulatory 
authorities.  
As defined in the risk-based monitoring (RBM) plan, approved by the Sponsor and provided 
separately, the responsible Monitor will periodically visit the study site at times agreed upon 
by the Investigator and the Monitor. Adaptations related to the on-site monitoring plan, when 
it is impossible or inappropriate to follow due to the COVID-19 pandemic, may be required 
such as supplementation with (additional/increased) centralised monitoring and central 
review of data if considered possible and meaningful. Results of adjusted monitoring/review 
measures should be reported to the Sponsor in monitoring reports and in the CSR. At the time 
of each monitoring visit, the role of the Monitor is (but not limited to) to: 
• provide information and support to the investigational team. 
• confirm that facilities and resources remain acceptable. 
• confirm that the investigational team is adhering to the CSP, applicable SOPs, 
guidelines, manuals and regulatory requirements.  
• verify that data are being accurately and timely recorded in the eCRFs and that IP 
accountability checks are being performed. 
• verify that data in the eCRF are consistent with the clinical records (SDV) in 
accordance with the RBM plan.  
• verify that the correct informed consent procedure has been adhered to for participating 
subjects.  
• ensure that withdrawal of informed consent to the use of the subject’s biological 
samples will be reported and biological samples are identified and disposed 
of/destructed accordingly, and that this action is documented and reported to the 
subject. 

 
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• verify that AEs are recorded and reported in a timely manner and according to the CSP. 
• raise and escalate any serious quality issues, serious GCP breach and any data privacy 
breach to the Sponsor.  
Centralised monitoring will also be performed continuously by study team members at CTC 
in accordance with the RBM plan.  
When the study has been completed and all queries have been resolved and the database has 
been locked, the Monitor will perform a close-out visit. 
15.3 Source data documents 
A separate Origin of Source Data List will be generated for each site before start of 
enrolment, specifying the location of the source of derived information appearing in the 
eCRF. This document must be signed by the Principal Investigator and the Monitor to confirm 
agreement before start of recruitment. 
Source documents are all documents used by the Investigator or hospital that relate to the 
subject’s medical history, that verifies the existence of the subject, the inclusion and exclusion 
criteria, and all records covering the subject’s participation in the trial. They include 
laboratory notes, memoranda, material dispensing records, subject files, etc. The eCRF may 
constitute source data if clearly defined in the Origin of Source Data List.  
The Investigator should guarantee access to source documents to the Monitor, CAs and the 
IECs, if required. 
15.4 Study agreements 
The Principal Investigator must comply with all the terms, conditions, and obligations of the 
Clinical Study Agreement for this study. 
Agreements between Sponsor and CTC must be in place before any study-related procedures 
can take place, or subjects be enrolled. 
15.5 Study timetable and end of study 
The study is expected to start in Q3 2020 and to be completed by Q4 2020. 
A subject is considered to have completed the study if he/she has completed all visits in the 
study including the last visit. The end of the study is defined as the date of the last visit of the 
last subject in the study. 
15.6 Termination of the study 
The Sponsor reserves the right to discontinue the study at any time but intends only to 
exercise this right for valid scientific or administrative reasons. 
After such a decision, the PI must inform all participating subjects and perform relevant 
assessments, preferably according to the scheme for the final assessments. All delivered and 
unused IP and other study materials must be returned and all eCRFs completed as far as 
possible. 

 
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15.7 Reporting and publication 
 Clinical study report  
After completion of the trial, a final study report will be written following the guidance in 
ICH Topic E3. A CSR, describing the conduct of the study, any statistical analyses performed 
and the results obtained, will be prepared by CTC. The report will be reviewed and approved 
by, as a minimum, the Principal Investigator, the Statistician and the Sponsor. 
 Confidentiality and ownership of study data 
Any confidential information relating to the IP or the study, including any data and results 
from the study, will be the exclusive property of the Sponsor. The Investigator and any other 
persons involved in the study are responsible for protecting the confidentiality of this 
proprietary information belonging to the Sponsor. 
 Publication 
The results from this study may be submitted for publication at the discretion of the Sponsor.  
15.8 Archiving  
The Principal Investigator is responsible for maintaining essential documents, (as defined in 
ICH E6 GCP, Section 8) for 10 years after finalisation of the CSR. This includes any original 
source documents related to the study, the Subject Identification List (providing the sole link 
between named subject source records and anonymous eCRF data), the original signed ICFs 
and detailed records of disposition of IP. 
It is the responsibility of the Sponsor to inform the Investigator/institution as to when these 
documents no longer need to be retained. 
The Sponsor will archive the TMF in accordance with ICH E6 GCP, Section 8 and applicable 
regulatory requirements. 
The data from the eCRFs will be sent to the Sponsor and a copy will be sent to the clinic and 
filed in the Investigator Study File for archiving for 10 years after finalisation of the CSR. 
The completed eCRFs are the sole property of the Sponsor and should not be made available 
in any form to third parties, except for authorised representatives of appropriate 
Health/Regulatory Authorities, without written permission from the Sponsor. 
 
 

 
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16 DATA MANAGEMENT 
The data management routines include procedures for handling of the eCRF, database set-up 
and management, data entry and verification, data validation, QC of the database, and 
documentation of the performed activities including information of discrepancies in the 
process. The database, data entry screens, and program will be designed in accordance with 
the CSP. 
Data validation/data cleaning procedures are designed to assure validity and accuracy of 
clinical data. These procedures consist of computerised online edit checks identifying e.g. 
data values that are outside the allowed range and SAS-programmed batch checks on data 
exports. All study-specific and standard data validation programming will be tested in a 
separate testing environment prior to use on production data. 
Detailed information on data management will be described in a study-specific Data 
Management Plan (DMP). 
16.1 The web-based eCRF 
Clinical data will be entered into a 21 CFR Part 11-compliant eCRF (Viedoc™) provided by 
Viedoc Technologies AB. The eCRF includes password protection and internal quality 
checks, such as automatic range checks, to identify data that appear inconsistent, incomplete, 
or inaccurate. Clinical data will be entered directly from the source documents or at bedside 
(if the eCRF data constitutes source data). Source data are to be defined at the site before 
inclusion of the first subject (Section 15.3). 
Authorised site personnel designated by the Investigator will complete data collection. 
Appropriate training and security measures will be completed with the Investigator and all 
authorised trial site personnel prior to the trial being initiated and any data being entered into 
the system for any study subject. 
16.2 The entering of data into the eCRF 
All entries, corrections, and alterations are to be made by the Investigator or designee. Neither 
the Monitor nor any other study team member besides site staff can enter data in the eCRF. 
All data should be entered in English. The eCRFs should be completed as soon as possible 
during or after the subject’s visit. To avoid inter-observer variability, every effort should be 
made to ensure that preferably the same individual who made the initial baseline 
determinations completes all corresponding follow-up evaluations. The Investigator must 
verify that all data entries in the eCRFs are accurate and correct. If some assessments are not 
done, or if certain information is not available, not applicable or unknown, the Investigator or 
assigned clinical staff should record such information in the eCRF. The Investigator will be 
required to electronically sign off the clinical data. This will be performed by means of the 
Investigator’s unique User ID and password; date and time stamps will be added 
automatically at time of electronic signature. 
16.3 The query process 
The Monitor will review the eCRFs and evaluate them for completeness and consistency. 
Data in the eCRF will be compared with the respective source documents to ensure that there 

 
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are no discrepancies for critical data as described in the RBM plan. All entries, corrections, 
and alterations are to be made by the Investigator or designee. Neither the Monitor nor any 
other study team member besides site staff can enter data in the eCRF.  
If corrections are needed, queries will be raised within the eCRF, either as a result of built-in 
edit checks or manually raised by the monitor. An appropriate member of the site staff will 
answer the queries in the eCRF either by correcting the data or by entering a response to the 
query. The monitor will either approve the answer/correction or re-issue the query. 
16.4 Audit trail 
All entries in the eCRF will be fully recorded in a protected audit trail. Once clinical data 
have been saved, corrections to the data fields will be audit trailed, meaning that the reason 
for change, the name of the person who made the change, together with time and date will be 
logged. 
16.5 External data 
External data consists of data that are not recorded in the eCRF. Data may be received in 
electronic format or as a paper printout. Key variables are defined in order to uniquely 
identify each sample record. File and data formats are agreed with the external data provider.  
16.6 Medical coding 
Medical coding will be performed by trained personnel at CTC. AEs and medical/surgical 
history verbatim terms will be coded using the Medical Dictionary of Regulatory Activities 
(MedDRA; latest version available at start of coding). Prior and concomitant medications will 
be coded according to the World Health Organisation (WHO) Anatomic Therapeutic 
Chemical (ATC) classification system. All coding will be approved by Sponsor prior to 
database lock. 
16.7 Database lock 
When all data have been entered and discrepancies solved, clean file will be declared, the 
database will be locked and the data will be analysed.  
 

 
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17 STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE  
The principal features of the statistical analysis to be performed are described in this section. 
A more technical and detailed elaboration of the principal features will be presented in a 
separate Statistical Analysis Plan (SAP), which will be signed and approved prior to database 
lock. 
Analyses of the primary and secondary endpoints will be performed by CTC. 
17.1 General 
Continuous data will be presented in terms of evaluable and missing observations, arithmetic 
mean, SD, median, minimum and maximum value. In addition, for the parameters AUC and 
Cmax the geometric mean and coefficient of variation (CV) will be presented.  
Categorical data will be presented as counts and percentages. When applicable, summary data 
will be presented by treatment, and by assessment time. Individual subject data will be listed 
by subject number, treatment, and, where applicable, by assessment time. 
All descriptive summaries and statistical analyses will be performed using SAS Version 9.4 or 
later (SAS Institute, Inc., Cary, NC). 
Baseline will be defined as the visit with last data collection point prior to the first use of IP. 
No imputation of missing data will be performed. 
For subject questionnaires measured at each PK time point, the Bonferroni-Holm p-value 
adjustment will be applied. 
17.2 Determination of sample size 
No formal sample size calculation has been performed for this study. The proposed sample 
size is considered sufficient to provide adequate information for the study objectives. 
Approximately 48 subjects will be screened to achieve 24 randomised subjects. 
17.3 Analysis data sets 
 Full analysis set 
The Full Analysis Set (FAS) will consist of all subjects who have been randomised and used 
at last one of the IPs and who has at least one post-baseline assessment of data.  
 Safety analysis set 
The Safety Analysis Set will comprise all subjects who used at last one of the IPs. 
 Per protocol set 
The Per Protocol Set (PPS) will consist of all subjects who have been randomised and 
completed the study without any major protocol deviations that are judged to compromise the 
analysis of the data. All protocol violations will be judged as major or minor prior to database 
lock. 

 
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 Pharmacokinetic analysis set 
The Pharmacokinetic analysis set (PKAS) will consist of all subjects who used at last one of 
the IPs and provided an evaluable plasma concentration profile and who have no AEs or 
protocol deviations judged to affect the PK analysis. Individual PK values may be excluded 
from the analysis as specified in the SAP. The PKAS will be used as the per protocol analysis 
set. 
17.4 Description of study population 
 Demographics and baseline characteristics 
Descriptive statistics for demographics, physical examinations, weight and height will be 
presented by sequence. 
 Medical/surgical history and prior/concomitant medication 
Medical/surgical history will be presented by system-organ-class (SOC) and preferred term 
(PT). Prior/concomitant medications will be presented by ATC level 3 and 5. 
Medical/surgical history and prior medications will be presented overall by descriptive 
statistics and listings. Concomitant medications will be presented by sequence. 
All data will be listed by subject. 
 Treatment compliance 
The number of subjects treated in sequence and their individual IP use will be listed. 
 Heaviness of smoking index 
Scores from the individual HSI will be presented with frequency tables including number of 
observations and percent. The sum of the 2 questions will be presented with descriptive 
statistics by sequence. 
17.5 Analysis of primary endpoints 
 Analysis of pharmacokinetics  
The PK analysis will be based on the PK analysis set and performed by CTC. The PK 
parameters will be calculated by non-compartmental analysis (NCA) using the software 
Phoenix WinNonlin® version 8.1 or later (Certara, U.S.A.).  
The following non-compartmental PK parameters will be determined for each IP use: 
• AUCinf (baseline adjusted [when possible] and non-baseline adjusted) 
• AUCt (baseline adjusted [when possible] and non-baseline adjusted) 
• 
AUC0-90 (baseline adjusted [when possible] and non-baseline adjusted) 
• Cmax (baseline adjusted [when possible] and non-baseline adjusted) 
• Clast (baseline adjusted [when possible] and non-baseline adjusted) 
• Tmax (baseline adjusted [when possible] and non-baseline adjusted) 

 
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• T½ (baseline adjusted [when possible] and non-baseline adjusted) 
 
Lambdaz (with acceptance criteria; R2, extrapolated AUC) will be calculated to support 
baseline adjustment of above PK parameters. 
Cmax and Tmax will be derived from the observed plasma concentration data. The AUC will be 
calculated using log-linear trapezoidal interpolation (linear - up, log – down). Calculations 
will be based on the actual sampling times recorded during the study. Concentrations below 
Lower limit of quantification (LLOQ) occurring before Cmax will be treated as zero. 
Concentrations below LLOQ occurring after Cmax will be omitted from the analysis. AUCt, 
and Cmax will be corrected for and calculated with and without nicotine baseline corrections. 
Where plasma nicotine concentrations are above the lower limit of quantification immediately 
prior to product use (-5 minutes), PK parameters will be calculated from baseline adjusted 
concentrations using subjects' elimination rate constant. 
Summary statistics for the PK parameters will be presented by product with number of 
measurements, arithmetic mean, SD, CV, median, minimum, maximum, geometric mean, 
geometric CV%. All data will be listed by subject. 
The primary objective will be examined by the following statistical comparisons for AUCt 
and Cmax: 
• Product A versus Product B, C, D and E, respectively 
• Product B versus Product C, D and E, respectively 
• Product C versus Product D and E, respectively 
• Product D versus Product E 
Log transformed nicotine Cmax and AUCt estimates will be evaluated separately in a linear 
mixed-effects analysis of variance model with fixed effects for period, sequence, and product, 
and a random effect for subject. If the assumptions for this model will be inappropriate will 
the fixed effects period and sequence be removed from the model. The above product 
differences will be back-transformed to present the ratios of geometric least squares (LS) 
means and 95% CIs of each test product versus each other from the same model. 
17.6 Analysis of secondary endpoints 
 Pharmacokinetics 
Refer to section 17.5.1. 
 In vivo extracted amount of nicotine 
The data needed for the analysis of in vivo extracted amount of nicotine are the individual 
data of amount of nicotine for unused reference pouches and the amount of nicotine left in the 
study pouches. The mean nicotine concentration of the reference pouch and weight of each 
individual study pouch and residual nicotine amount will be used to calculate the extracted 
amount. The mean of extracted amount (mg/unit) and extraction fraction (%) of nicotine for 
each IP pouch, will be calculated. The extracted dose of nicotine will be analysed using the 
signed Wilcoxon rank sum test for within subject difference (i.e. between IPs). Amount of 

 
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nicotine in reference pouches and in used pouches will be presented through descriptive 
statistics. 
 Products evaluation scale 
Each sub-question, sub-category and the total score of Questions 1a-g (sub-category 1), 2a-j 
(sub-category 2), 3a-y (sub-category 3) and 4a will be presented using descriptive statistics at 
selected timepoints by product including a graph of the mean at each time point.  
The total score of PES and the sub-categories will be calculated for each product and 
intraindividual difference for each timepoint assessed will be analysed using a Wilcoxon 
Signed Rank Sum test. 
 Modified cigarette evaluation questionnaire 
Frequency (number and percentage) for each sub-question will be presented using tables. 
 Products preference scale 
The sub-questions 1 will be presented using a frequency table with number of observations 
and all combinations of the subject’s preference. 
The sub-question 2 will be presented using a frequency table with number of observations and 
percent. 
No statistical testing will be performed on sub-questions. 
 Adverse events  
An overview of all AEs, including SAEs, intensity, relationship to IP, and deaths will be 
presented by SOC and PT. 
Incidence of AEs and SAEs will be summarised by SOC and PT by sequence and overall.   
All AE data will be listed by subject and include the verbatim term entered by the 
Investigator. 
 Clinical laboratory analyses 
Clinical laboratory data will be summarised overall with absolute and percent change from 
baseline. 
Abnormal, clinically significant values will be summarised separately, if considered 
appropriate.  
All data will be listed by subject. 
 Vital signs 
Vital signs (systolic/diastolic blood pressure and pulse) will be summarised by sequence. Data 
will be presented with absolute and percent change from baseline. 
All data will be listed by subject. 

 
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  12-lead ECG 
All ECGs will be categorised as ”normal”, ”abnormal, not clinically significant”, or 
”abnormal, clinically significant” (as judged by the Investigator) and summarised by sequence 
using frequency tables.  
Changes over time will be presented using shift tables, if considered appropriate. 
All data will be listed by subject. 
 Total exposure (cotinine in plasma) 
The analysis and presentation of total nicotine exposure following plasma cotinine levels 
(concentration, applicable calculated PK parameters and number of ad lib IP units used) 
following controlled single use and ad lib use of IP will be further specified in the SAP. 
 
 

 
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18 REFERENCES 
1. World Medical Association, WMA Declaration of Helsinki – Ethical principles for medical 
research involving human subjects [website], https://www.wma.net/policies-post/wma-
declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/, 
(accessed 10JUN2020) 

 
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19.2 Signature page (approval of the clinical study protocol) 
 
 
Sponsor signatories