Free-Base Nicotine or Nicotine Salt e-Liquids in Current E-Cigarette Smokers, PeloPET
Phase: NA
Conditions: Cigarette Smoking-Related Carcinoma
Sponsor: Ohio State University Comprehensive Cancer Center

LAST REVIEWED AND IRB APPROVED JULY 26, 2023        
“THE IMPACT OF E-CIGARETTE LIQUID NICOTINE 
FORM ON PUFFING BEHAVIOR, ABUSE LIABILITY, 
AND CANCER RISK” (NCT05455086) 
 
 
 

IRB Protocol Number: 2021C0088 
IRB Approval Original Date: 08.27.2021 
Version: 4.0 
 
 
The impact of E-cigarette liquid nicotine form on puffing behavior, 
abuse liability, and cancer risk (PeloPET) 
Table of Contents 
A. 
Abstract ................................................................................................................................................. 3 
B. 
Specific Aims ......................................................................................................................................... 3 
C. 
Significance ........................................................................................................................................... 4 
D. 
Approach and Preliminary Studies ........................................................................................................ 5 
E. 
Research Design and Methods ............................................................................................................. 6 
i. 
Design Overview ............................................................................................................................... 6 
ii. 
Study Procedures .............................................................................................................................. 7 
F. 
Recruitment Feasibility and Retention ................................................................................................. 9 
i. 
Recruitment ...................................................................................................................................... 9 
ii. 
Informed Consent ............................................................................................................................. 9 
iii. 
Retention ........................................................................................................................................ 10 
iv. 
Compensation .................................................................................... Error! Bookmark not defined. 
G. 
Detailed Study Procedures ..................................................................... Error! Bookmark not defined. 
i. 
Measurement/Instrumentation ......................................................... Error! Bookmark not defined. 
ii. 
Study Products ................................................................................................................................ 10 
H. 
Protocol Adherence and Quality Control ............................................................................................ 12 
I. 
Measures ............................................................................................................................................. 12 
i. 
Outcome Measures ............................................................................ Error! Bookmark not defined. 
J. 
Statistical Methods ............................................................................................................................. 13 
i. 
Power Analysis ................................................................................... Error! Bookmark not defined. 
ii. 
Data Analytic Plan .............................................................................. Error! Bookmark not defined. 
iii. 
Missing Data ....................................................................................... Error! Bookmark not defined. 
K. 
Gender/Minority/Pediatric Inclusion for Research ............................................................................ 14 
i. 
Inclusion of Women and Minorities ............................................................................................... 14 
ii. 
Inclusion of Children ....................................................................................................................... 15 
L. 
Human Participants ............................................................................................................................. 15 
i. 
Potential Risks ................................................................................................................................. 15 
ii. 
Protections Against Risk .................................................................................................................. 15 
M. 
Data and Safety Monitoring Plan and Board .................................................................................. 17 

IRB Protocol Number: 2021C0088 
IRB Approval Original Date: 08.27.2021 
Version: 4.0 
 
 
i. 
Plan.................................................................................................................................................. 17 
ii. 
Adverse Events ................................................................................... Error! Bookmark not defined. 
N. 
Literature Cited ................................................................................................................................... 20 
 
 
 

IRB Protocol Number: 2021C0088 
IRB Approval Original Date: 08.27.2021 
Version: 4.0 
 
 
A. Abstract 
Since their market emergence, electronic cigarettes (ECs) have garnered both criticism and praise 
regarding their potential promise to reduce the risks associated with conventional cigarette use.  While 
researchers have attempted to keep pace, ECs and e-liquids have rapidly evolved.  Over the last two 
years there has been a significant surge in EC sales and use among youth and adults alike, drawing 
significant concern from health officials and regulators.  The surge appears to be largely driven by a new 
category of EC—nicotine salt-based (NSB) devices, of which the most well-known is JUUL, garnering 
nearly 80% of the e-cigarette market.  Unlike previous ECs that relied on unprotonated, or “free-base” 
nicotine e-liquid, NSB devices use protonated forms (i.e., nicotine salts) by combining nicotine with an 
acid.  With a shift to protonated forms of nicotine in e-liquid, inhaling high concentrations of nicotine (3-
6%) is much more palatable.  With improved sensory experience and higher concentrations of nicotine, 
use of protonated forms may result in 1) more intense puffing, with potential for greater deposition and 
absorption of nicotine deeper into the respiratory tract influencing lung cancer risk, and 2) greater 
nicotine delivery, abuse liability, and appeal to non-users, a concerning finding since ECs contain 
numerous carcinogens and many EC users go on to smoke conventional cigarettes.  To begin to examine 
the risk-benefit of e-liquid nicotine form, the overall aim of the proposed study is to evaluate the effect 
of free-base nicotine vs. nicotine salt e-liquids on EC puffing behavior, abuse liability, deposition and 
absorption of nicotine in the respiratory tract.  Using a randomized crossover-design, up to 30 adult EC 
users will complete four standardized EC puffing sessions inside the Positron Emission Tomography (PET) 
scanner, with two e-liquids that differ primarily by the dominant nicotine form.  E-liquid will be prepared 
with unlabeled and radiolabeled 11C-nicotine for PET imaging to determine the impact of nicotine form 
on: 1) changes in EC puffing behavior; 2) EC abuse liability; and 3) nicotine deposition and absorption in 
the respiratory tract.  The study has the potential for high public health impact as it will provide the 
scientific foundation the FDA and other public health agencies need to establish effective regulatory 
strategies for the manufacture, distribution, and marketing of ECs. 
B. Specific Aims 
Since their market emergence, electronic cigarettes (ECs) have garnered both criticism and praise 
regarding their potential promise to reduce the risks associated with conventional cigarette use.  While 
researchers have attempted to keep pace, ECs and e-liquids have rapidly evolved.  Over the last two 
years, there has been a significant surge in EC sales and use among youth and adults alike1,2, drawing 
significant concern from health officials and regulators, as e-cigarettes expose users to addictive 
nicotine, and toxic and carcinogenic carbonyls, furans, reactive oxygen species, and heavy metals3,4. The 
surge appears to be largely driven by a new EC category—nicotine salt-based (NSB) devices, of which the 
most well-known is JUUL, garnering nearly 80% of the e-cigarette market5.  Unlike previous ECs that 
relied on unprotonated, or “free-base” nicotine e-liquid, NSB devices use protonated forms (i.e., 
nicotine salts) by combining nicotine with an acid.  While past research indicates that protonated 
nicotine is significantly less harsh to inhale6, it is not yet clear what impact this will have on EC puffing 
patterns, abuse liability, and downstream health effects.  Making conventional cigarettes easier to 
inhale was associated with more aggressive and frequent puffing and increased lung cancer disease 
risk7.  Whether this holds true for NSB devices is yet to be seen.  
 
Consistently utilizing free-base nicotine in their e-liquids, the evolution of early EC models centered on 
increasing device power (wattage) delivered to the heating coil.  This strategy was successful in terms of 
improved nicotine delivery, but also had several unanticipated and negative effects8.  Increased power 

IRB Protocol Number: 2021C0088 
IRB Approval Original Date: 08.27.2021 
Version: 4.0 
 
 
led to increased user exposure to tobacco toxicants due to greater production of carcinogenic 
compounds in the EC aerosol.  However, with increased heating came compensatory puffing as users 
began reducing the concentration of nicotine in their e-liquid (<1.2%) to improve their sensory 
experience (high doses of free-base nicotine at high wattage are very harsh)8-11.  
 
With protonated forms of nicotine in e-liquid, inhaling high concentrations of nicotine salts (3-6%) is 
much more palatable, allowing smaller, inconspicuous low-powered EC devices to provide effective 
nicotine delivery12,13.  This combination of high nicotine but low power may be beneficial in terms of 
reduced exposures to tobacco-related toxicants, including lower heating of the coil, reducing the 
amount of toxicants produced and higher levels of nicotine per puff, reducing the number of puffs 
needed to achieve satisfying nicotine levels14.  On the other hand, with smaller, easily hidden devices, 
improved sensory experience, and higher concentrations of nicotine, use of nicotine salts may result in: 
1) more frequent dosing; 2) more intense puffing, with potential for greater deposition and absorption 
of nicotine deeper into the respiratory tract influencing lung cancer risk; and 3) greater nicotine delivery, 
abuse liability, and appeal to non-users, a concerning finding since ECs contain numerous carcinogens 
and many adolescent EC users go on to smoke conventional cigarettes14,15. 
 
To begin to examine the risk-benefit of e-liquid nicotine form, the overall aim of the proposed study is 
to evaluate the effect of free-base vs. nicotine salt based e-liquids on EC puffing behavior, abuse 
liability, and deposition and absorption of nicotine in the respiratory tract.  Using a randomized 
crossover-design, up to 30 adult EC users will complete three study visits that include four 1-puff 
standardized EC sessions, with two e-liquids that differ only by the dominant nicotine form.  For visits 
that include PET scanning, each e-liquid will be prepared with [11C]-nicotine for PET imaging to 
determine amount and location of deposition and absorption of nicotine in the brain and respiratory 
tract.  Imaging visits will be preceded by 12 hours of nicotine abstinence, and sessions will be separated 
by approximately 2 hours to allow an estimated 6 half-lives of [11C]-nicotine decay.  Outcome measures 
will include: 1) puffing topography captured by the study EC device; 2) abuse liability including reported 
drug liking/satisfaction and measured amount and rate of uptake of [11C]-nicotine in the brain during the 
puffing sessions; and 3) respiratory tract deposition and absorption of [11C]-nicotine.  
 
Aim 1: To examine the influence of nicotine form on puffing behavior and abuse liability. H1a: NSB e-
liquid will result in puffs of longer duration and higher flow rate, and H1b: demonstrate greater abuse 
liability. H1c: FB nicotine will result in puffs of shorter duration, lower flow rate, lower inhaled volume, 
and lower abuse liability. 
 
Aim 2: To evaluate the influence of nicotine form and concentration on nicotine distribution in the 
brain and respiratory tract. H2. Compared to FB nicotine, nicotine salts will result in greater nicotine 
distribution in the lower (vs. the upper) respiratory tract and greater amount and rate of uptake in the 
brain. 
C. Significance 
The cost-benefit of ECs continues to be debated in the public health literature.  ECs are now the most 
commonly used tobacco product in the U.S. among youth and young adults and anticipated to exceed 
total conventional cigarette use by 20201.  The most recent estimates indicate that 10.8 million US 
adults (4.5%) have used an EC in the past 30 days2.  Among high school students and young adults (18-24 
years), these rates are even higher, at 3.1 million (20.8%) and 2.8 million (9.2%), respectively1. 
 

IRB Protocol Number: 2021C0088 
IRB Approval Original Date: 08.27.2021 
Version: 4.0 
 
 
EC prevalence rates have increased significantly over the last two years, nearly doubling for youth and 
young adults, with the emergence of nicotine salt-based (NSB) devices1.  Indeed, several recent studies, 
including those conducted by our team, suggest that NSB devices are not only seen as more appealing 
due to their small, sleek styling, and smooth delivery of high doses of nicotine, but that youths and 
adults who try NSB devices are far more likely to become regular users compared to those who try free-
base ECs, with approximately 40-60% of those who ever tried an NSB device, identifying as current 
users. 
 
While the long-term health effects are still unclear, studies examining proximal biomarkers of health 
indicate that EC users are exposed to toxic and carcinogenic carbonyls, furans, reactive oxygen species, 
and heavy metals and experience adverse health effects, including increased oxidative stress, 
respiratory and mucosal inflammation, and adverse cardiovascular effects.  These data suggest that 
sustained EC use will likely have notable adverse health effects4, yet to our knowledge, no studies have 
examined the toxicological and physiological effects of NSB use.  All previous toxicological EC studies 
have focused on free-base nicotine devices, and only two studies, to our knowledge, both conducted by 
our team and currently in preparation for publication, have examined the pharmacological profile of 
NSB devices. 
 
Consequently, we do not have sufficient data to determine what impact the use of protonated nicotine 
in ECs will have on smoking behaviors, abuse liability, and health, nor what will be the most effective 
regulatory strategies to protect public health.  The proposed study will begin to address the current 
knowledge gap by directly examining the effect of free-base vs. nicotine salt e-liquids on EC puffing 
behavior, abuse liability, and deposition and absorption of nicotine in the respiratory tract and rate of 
uptake in the brain.  The results from this study will provide much needed scientific information to 
public health officials and regulators. 
 
Innovation 
There is a dearth of research examining behavioral effects of NSB devices, the most widely used ECs on 
the market, and no published studies examining their pharmacological, toxicological, and physiological 
effects.  The proposed study will be the first to systematically examine the impact of the nicotine form 
(free-base vs. protonated) in e-liquids on EC puffing behavior, abuse liability, and deposition and 
absorption of nicotine in the respiratory tract.  Moreover, the use of [11C]-nicotine for PET imaging will 
provide clear resolution and definitive conclusions as to the rate of nicotine delivery to the brain (critical 
for the initiation and maintenance of nicotine addiction) and the amount and location of nicotine 
deposition to the respiratory tract (critical for understanding uptake of nicotine in the body).  
 
D. Approach and Preliminary Studies 
Our team brings combined expertise in all areas necessary for the successful implementation of a 
human laboratory study examining the impact of nicotine form (free-base vs. protonated) in EC liquid on 
puffing behavior, nicotine delivery, abuse liability, deposition, and resulting harm from vaping ECs.  
Specifically, we have conducted nearly 20 human laboratory studies examining the behavioral, 
pharmacological, toxicological, and/or physiological effects of non-cigarette tobacco products including 
5 ongoing NIH studies, 3 examining ECs.  We have also recently conducted 4 studies examining NSB EC 
devices16,17, including two recently completed human laboratory studies (manuscripts in prep; see 
submitted abstracts10,11). Results of these studies demonstrated that NSB ECs achieved cigarette-like 
levels of nicotine delivery, have the potential for significant levels of addiction, and that higher levels of 

IRB Protocol Number: 2021C0088 
IRB Approval Original Date: 08.27.2021 
Version: 4.0 
 
 
protonated nicotine (i.e., lower e-liquid pH) was associated with reduced perceived harshness of the 
aerosol, increased nicotine uptake, and higher abuse liability.  We have an established toolkit of 
validated methodologies and standard operating procedures for use in this study.  Our team has also 
conducted several short-term as well as long-term randomized trials assessing tobacco use behavior.  
Additionally, the radiochemistry and imaging teams at the Wake Forest Clinical and Translational Science 
Institute (CTSI) have extensive experience in radiosynthesis and analysis of [11C]-nicotine and with a 
variety of imaging approaches, including the dynamic perfusion imaging that will be utilized in this study.  
A methodology for imaging usage of a radiolabeled EC e-liquid in real time has been fully developed with 
the assistance and approval of University Radiation Safety staff and the process is ready for final 
optimization and immediate imaging sessions with use of [11C]-nicotine.  
 
E. Research Design and Methods 
i. 
Design Overview 
Utilizing a 4-session, within-subjects, factorial design, up to 30 e-cigarette users (10 NSB EC users; 10 FB EC 
users) will attend 3 laboratory visits at Wake Forest Baptist Medical Center’s PET Research Facility.  At the 
first visit, they will select the flavor they can tolerate and vape in both the free-base and nicotine salt form 
without coughing (see Figure 1 for e-liquid combinations).  For the remaining two visits, they will complete 
four standardized, single-puff vaping sessions (2 sessions/visit) using the same EC device, containing 
unflavored or flavored e-liquid and radiolabeled [11C]-nicotine and native nicotine (3%) either predominantly 
in the free-base or protonated form.  The initial orientation visit will include informed consent, a health 
screening/physical exam, and a vaping session in which they will learn to use the study EC (Reflex, Evolv LLC, or 
similar) and sample 4 e-liquids to determine whether they can vape the unflavored e-liquid without coughing.  
The subsequent two visits will include PET scanning of the head and chest (two separate scanning sessions), 
each after a single-puff vaping session.  The nicotine form (free-base or protonated) will be randomly selected 
for the visit in the flavor (flavored vs. unflavored) selected at the first visit, as will the order of the focal area of 
scanning (e.g., first head, then chest).  At the final visit, the participant will vape the other nicotine form in the 
flavor selected in visit 1, and the order of the focal area of scanning will be randomly selected.  
 
 
 
 
 
 

IRB Protocol Number: 2021C0088 
IRB Approval Original Date: 08.27.2021 
Version: 4.0 
 
 
ii. 
Study Procedures 
All study visits will take place at in North Carolina, specifically the WAKE Health Research PET Center, 
where participants will be given consent form, complete screening procedures, vaping sessions, PET/CT 
scans, and complete online questionnaires and surveys on a tablet. Physical materials will be stored in a 
locked file cabinet, locked office or suite at the WAKE Health Research PET Center, 2036 Queen Street, 
Winston Salem, NC 27157 only. Electronic data will be entered, stored, and secured through REDCap 
and managed by Ohio State University. Tablets will be supplied by Ohio State. 
 
Visit #1:  
Participants will complete an online screening questionnaire determining eligibility prior to the visit.   
Once deemed eligible, participants will come into the laboratory to give informed consent, and 
participate in health screening/physical exam and a vaping session in which they will learn to use the 
study device (Reflex, Evolv LLC, or similar) and sample 4 e-liquids at 3% nicotine concentration to 
determine whether they can vape both nicotine forms (free-base and protonated).  The 4 e-liquids will 
vary based on flavor (unflavored and flavored) and protonation level (0-100%). The unflavored set of 
two e-liquids (0% and 100% protonation) are the preferred test articles, but if the participant cannot 
vape four puffs from each of them without coughing, then they will sample the flavored set of two e-
liquids (0% and 50% protonated) to determine if they can vape four puffs from each of them without 
coughing.  Puffing topography captured by the study EC will be collected to determine the participant’s 
typical puff volume for each e-liquid tested.  If the participant cannot vape the test e-liquids without 
coughing, they will be deemed ineligible for further participation.  Eligible participants will be given a 
study device and 1 pod of each test e-liquid to take home and practice using at least 3 days (20 puffs per 
day with the study device and until they feel comfortable using the device) so that they can become 
familiar with using the study device and the test e-liquids. After review of the topography data stored on 
the device, participants that vape small volumes (<20 mL per puff) may be deemed ineligible from 
further participation.  Participants will also be provided instructions that they must remain nicotine 
abstinent for 12 hours before Visit #2 and Visit #3.   
 
Visit #2:  
Following confirmation of 12-hour nicotine abstinence from combustible tobacco products via exhaled 
CO (<10ppm), and after confirmation that participants practiced at least 3 days with the device and pods 
using the test e-liquids, participants will be randomized to nicotine form (free-base or protonated) using 
either unflavored or flavored e-liquid (determined from Visit #1) and order of the focal area of scanning 
(head/neck or chest). Participants will also complete a questionnaire assessing several measures of 
evaluating the perceived abuse liability of the study e-liquids.  Participants will complete a standardized 
1-puff vaping bout using the same device, with the same e-liquid, flavor, and nicotine, propylene glycol, 
and glycerol concentration.  Specifically, participants will be randomized to undergo a dynamic scanning 
sequence (either 0-15 min head and 5 min chest scan, or 0-15 min chest and 5 min head scan).  The 
imaging agent, [11C]-nicotine, will be delivered to the participant by the participant taking a single puff of 
the e-liquid (protonated or unprotonated), in prone position inside the PET scanner; puff duration and 
volume will be determined by the participant (ad libitum).  After the first scanning session is complete, 
the participant will rest outside the scanner for a >1-hour washout period so that the [11C]-nicotine can 
decay (6 half-lives).  Participants will not be permitted to leave the PET center waiting lobby and cannot 
leave the facility (except for restroom breaks). 
 

IRB Protocol Number: 2021C0088 
IRB Approval Original Date: 08.27.2021 
Version: 4.0 
 
 
The participant will repeat the single puff vaping bout with the same e-liquid, but will be scanned 
according to the other dynamic sequence.  At least a 1-week period should elapse between visits 2 and 
3. 
 
Visit #3: 
Visit #3 is essentially identical to Visit #2, but the participant will conduct the two single puff vaping 
bouts using the e-liquid containing the other form of nicotine.  
  
  
  
Visit 
PET  
CT - Anatomic 
Visit #1: Informed consent; select 
test article; puffing topography 
None 
None 
Visit #2a: 
1 puff (ad lib) of [11C]-Nicotine 
with protonated nicotine 
0-15 min head scan;      16-20 
min chest scan  
Head 
Chest 
  
WASHOUT PERIOD of >1 h 
  
Visit #2b: 
1 puff (ad lib) of [11C]-Nicotine 
with protonated nicotine 
0-15 min chest scan;      16-20 
min head scan 
Chest 
Head 
≥1 WEEK 
Visit #3a: 
1 puff (ad lib) of [11C]-Nicotine 
with unprotonated nicotine 
0-15 min head scan;      16-20 
min chest scan  
Head 
Chest 
  
WASHOUT PERIOD of >1 h 
  
Visit #3b: 
1 puff (ad lib) of [11C]-Nicotine 
with unprotonated nicotine 
0-15 min chest scan;      16-20 
min head scan 
Chest 
Head 
DEBRIEFING 
  
                                   Table 1. Activities conducted during participant laboratory visits. 
 

IRB Protocol Number: 2021C0088 
IRB Approval Original Date: 08.27.2021 
Version: 4.0 
 
 
F. Recruitment Feasibility and Retention 
i. 
Recruitment 
A total of up to 30 current e-cigarette users (aged 21-50 years) will be recruited from the general 
community via targeted internet advertisements i.e., local newspaper, advertisements, craigslist, 
Facebook, Instagram, and Twitter as well as flyers and word-of-mouth advertising in the North Carolina 
Triad Area (Greensboro, Winston-Salem, and High Point).  Based on our team’s previous studies, we 
conservatively assume a 20% attrition rate. Participants will complete an online screener questionnaire, 
and those who meet the following eligibility criteria will be asked to take part in the study. 
 
 
Inclusion criteria:  
1) A current e-cigarette user (≥1 vaping bout per day) for at least the past 6 months 
(confirmed by NicAlert saliva testing strip or similar test) 
2) Between 21-50 years old 
3) Willing to provide informed consent and abstain from all tobacco, nicotine, and 
marijuana use for at least 12 hours prior to visits 2 and 3 
4) Willing to participate in 3 laboratory visits 
5) Read, write, and speak English 
6) If utilizing study provided rideshare services, will need to live within 20 miles from 
Wake Forest University 
Exclusion criteria: 
1) Self-reported diagnosis of lung disease including asthma, cystic fibrosis, or chronic 
obstructive pulmonary disease 
2) Unstable or significant psychiatric conditions (past and stable conditions will be 
allowed) 
3) History of cardiac event or distress within the past 3 months 
4) Currently pregnant (as indicated by urine pregnancy test at the start of each laboratory 
visit), planning to become pregnant, or breastfeeding (women only) 
5) Use of other tobacco products (e.g., cigarette, cigar, etc.) >5 days in the past month 
6) Currently engaging in a tobacco product cessation attempt 
 
Assessment of Eligibility 
Interested potential participants will respond to online advertisements and complete an online 
screening questionnaire to determine eligibility.  Eligible participants interested in participating will be 
scheduled for the physical examination and then scanning at the PET center.  After obtaining their 
informed consent, potential participants will be asked about their medical history, including smoking 
history, and will have their pulse, weight, height, and temperature measured.  A urine pregnancy test 
(dipstick) will also be performed for women of childbearing potential at each visit.  Potential participants 
who do not have a self-reported diagnosis of the exclusion conditions may be excluded if the study 
physician determines that the history, physical findings, or laboratory studies reveal information that 
may jeopardize the participant’s safe study participation.  
 
ii. 
Informed Consent 
Informed consent (including a description of the nature, purpose, risks, and benefits of the study) will 
take place through both oral and written explanation of the study. A legally valid signature will be 
obtained via REDCap. The voluntary nature of the study and the participant’s right to withdraw at any 

IRB Protocol Number: 2021C0088 
IRB Approval Original Date: 08.27.2021 
Version: 4.0 
 
 
time will be stressed during the consent process; a copy of the informed consent will be provided to the 
participant in written form at the time of consent for them to keep (even if they sign electronically in 
REDCap).  Informed consent will be collected by IRB-approved study personnel.  The Ohio State 
University Institutional Review Board will approve recruitment scripts and materials, consent forms, and 
all study procedures .  All participants will provide written consent before any study data are collected. 
 
iii. 
Compensation and Retention 
Participants will be compensated $50 for completing Visit #1, and an additional $20 if they bring the 
device back to the laboratory for their Visit #2.  Participants will be compensated $400 for completing 
Visit #2 and $500 for completing Visit #3.  Total participant remuneration, if all visits are completed and 
the study EC device, is returned is $970.  To recruit and retain participants, as well as decrease attrition, 
rideshare services (i.e., Uber and Lyft) will be made available to participants (within 20 miles or less of 
the study location) as a transportation option to and from study visits. 
Additionally, to ensure that the utilization of the PET scanner is maximized, participants will be given the 
opportunity to volunteer as an alternate for a no-show participant on a visit 2 that is scheduled prior to 
their regularly scheduled study visit 2.  They will be compensated an additional $25 to be an alternate 
whether the regularly scheduled participant shows for their study visit or not.  If the regularly scheduled 
study participant shows (within 15 minutes of their regularly scheduled appointment time), the 
alternate will be scheduled at their regular visit 2 time, receive $25 compensation for serving as an 
alternate, and return home.  If the regularly scheduled participant does not show, the alternate will take 
the place of the regularly scheduled participant attending visit 2. 
If participants attend a visit and there are technological issues, error, or chemistry fails (i.e. – 
cyclotron/scanner/radiochemistry module/hot e-liquid production) preventing the visit from occurring, 
participants will be compensated $50 for their time and inconvenience.  If participants attend Visit #2 
and/or #3 and their first scan is successful, but the second scan is not, due to technological issues, error, 
or chemistry fails, they will receive partial compensation (half of the visit compensation) for the 
designated amount of that visit (i.e. - $200 and $250 for Visits #2 and #3, respectively). 
Payments will be made using the Greenphire ClinCard to increase accountability and facilitate ease of 
payment.  We will also facilitate study visits by offering evening and weekend appointments and additional 
retention strategies (e.g., multiple sources of contact, reminder calls/texts/emails).  These methods are 
consistent with our team’s previous and current studies and have resulted in strong retention rates. 
iv. 
Study Products 
EC Device:  All participants will complete puffing sessions using an Evolv Reflex device (Figure 2), which 
is able to vape both FB and NSB e-liquid.  Device specifications include:  750mAh battery, 3-25 watts 
output range, 2ml pod capacity, 37.5 grams weight, 1.0 amps of charging current, and 84mm x 300mm x 
11mm dimensions with the pod installed.  We will use the eScribe software available to retrieve 
information about the participant’s use of the product in the field (and during the standardized puff 
session) including the number of puffs, puff duration, puff volume, flow rate, time of day puff was taken, 
wattage, coil temperature for each puff, and inter-puff-interval, which we view as a great strength.  A 
new e-liquid pod will be used for each participant and each puffing session.  Participants will be provided pre-
filled and weighed e-liquid pods. 

IRB Protocol Number: 2021C0088 
IRB Approval Original Date: 08.27.2021 
Version: 4.0 
 
 
 
Figure 2. Study EC Device 
 
  
E-liquid:  There is no known commercial pair of nicotine liquids that differ only by nicotine form.  
For this study, we will prepare four [11C]-nicotine liquids that differ by nicotine form (due to 
presence/absence of benzoic acid) and nicotine concentration, simulating characteristics of 
popularly used nicotine liquids13,18.  Radiolabeled [11C]-nicotine will be prepared according to the 
method previously developed by our team19. (Solingapuram et al, JNM 2019, 13:36) Table 2 
summarizes the key ingredients of the test liquids, which will be prepared from pure, “cold” 
(≥99%) (S)-nicotine; protonation and dilution of the radiolabeled nicotine will be done using USP 
grade benzoic acid (Low pH/protonated only), and glycerol and propylene glycol, respectively.  
[11C]-labeled (S)-nicotine will be produced by our team according to applicable production 
guidelines for inhalants19(Solingapuram et al, JNM 2019, 13:36).  In short, purified [11C]-labeled (S)-
nicotine will be formulated with the corresponding e-liquid.  The [11C]-labeled (S)-nicotine 
concentration, radiochemical purity, bacterial endotoxin levels, and specific activity will be 
determined post-synthesis following all the approved SOPs.  After formulation, appropriate 
amount of the e-liquid containing [11C]-nicotine will be loaded in the e-cigarette cartridge in the 
PET scanner room.   The total radioactivity in the cartridge of the e-cigarette will not exceed a 5.0 
mCi dose delivered to the patient. The release of radioactivity is expected to be 15 +/- 5% during 
the inhalation phase20. The total delivered dose to the participant will be determined and 
recorded. We will submit an Investigational Tobacco Product application to the U.S. FDA to receive 
approval for the e-liquids. 
 
Table 2. Identity and mass of main ingredients used to make the study e-liquids. 
ITP 
Name 
(–)-Nicotine 
(g) 
Benzoic acid 
(g) 
Vegetable 
Glycerol (g) 
Propylene 
Glycol (g) 
e-Liquid 
Flavoring (g) 
Total Mass 
(g) 
T3FB 
22.50 
none 
(a) 
(a) 
727.50 Ghost 
750.00 
T3NS 
22.50 
16.94 
(a) 
(a) 
710.56 Ghost 
750.00 
U3FB 
22.50 
none 
509.25 
218.25 
none 
750.00 
U3NS 
22.50 
16.94 
497.39 
213.17 
none 
750.00 
(a) The mass ratio of propylene glycol to vegetable glycerol (PG:VG) is 30:70.  
 

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G. Protocol Adherence and Quality Control 
All research staff will have completed Human Subjects and HIPAA training.  Standard operating 
procedures (SOP) will be developed and all staff will be trained to ensure adherence to the SOP.  As is 
standard practice for our team’s current studies, each visit will have its own checklist of specific 
measures to be completed and the order in which they are to be administered.  To reduce data entry 
errors, we will use secure computer-based questionnaires for participants to complete, including daily 
diaries.  All key on-site personnel will meet face-to-face weekly throughout the entire study.  Off-site 
investigators will also participate in these weekly meetings during the first year for project start-up; 
however, this will be reduced to every other week as the study progresses.  During these meetings, 
recruitment, enrollment, data collection, data monitoring results, and any concerns or issues that may 
arise will be discussed.  We will also plan for all key personnel to meet (virtually) at the Ohio State 
University and Wake Forest University sites in the first year for start-up and then in the final year to 
discuss analyses, manuscripts, and future research based off of this study.  
 
H. Measures 
All measures, summarized in Table 3, have been used and validated previously by our team. 
Questionnaire data will be collected electronically into a secure, encrypted database (REDCap) by a 
trained research assistant.  Sociodemographic measures will assess participant age, sex, marital status, 
ethnicity, employment status, occupation, years of education, and socioeconomic status.  Tobacco use 
history will assess years of tobacco use, age of first use, tobacco type, brand, frequency, quantity, and 
duration of use all of nicotine/tobacco products including cigars, cigarillos, little cigars, pipe tobacco, 
chewing tobacco, snuff, snus, EC/vape/mod/APV/e-hookah, and hookah tobacco.  EC Dependence will 
be measured with a modified 12-item Cigarette Dependence Scale21.  Abuse liability of products will be 
measured by self-report of subjective effects, including an adapted version of the Drug Effects/Liking 
Questionnaire will assess the desire and liking of both study products, positive and negative effects (i.e., 
side effects), and perceived strength and effectiveness.  The modified Cigarette Evaluation 
Questionnaire (mCEQ)22 will also assess subjective responses to e-cigarettes (e.g., reward, 
satisfaction)23,24.  EC puff topography will be measured with the study EC device, including measures of 
puff count, puff duration, inter-puff-interval, puff flow rate, average puff volume, and total puff volume.  
Puff topography is a validated and sensitive behavioral measure of abuse liability, is highly stable and 
associated with level of dependence, and predicts level of exposure to harmful tobacco-related 
toxicants25--27.  To corroborate 12-hour nicotine abstinence prior to visits 2 and 3, e-cigarette 
urges/craving will be measured using the 10-item Tiffany-Drobes Questionnaire of Smoking Urges: Brief 
Form 28.  A modified version (replacing the word “cigarette” with “e-cigarette”) for e-cigarette users and 
use conditions.  Additionally, nicotine withdrawal will be assessed using the empirically validated 15-
item version of the Minnesota Nicotine Withdrawal Scale29. 
 
[11C]-nicotine formulated with a specific eLiq (protonated or free-base) will be produced at the Wake Forest 
PET Research Center.  Subjects will be inhaling a single puff of vapor containing [11C]-nicotine in either 
protonated or free-base e-Liquid (10 µL).  Dynamic 0-15 min PET imaging will be obtained in the head-neck 
regions followed by a 5 min chest (oral cavity-lungs) scan.  The same scan will be repeated with both the e-
liquid formulations with 0-15 min chest and 5 min head scans.  The subject will be scanned for 15 min in a 
sequence of 245 frames of 1-4 sec each.  Followed by it, a 5 min scan is obtained from regions below the head 
i.e., oral cavity, trachea, esophagus, bronchi and lungs.  All the images will be conducted using GE PET/CT 
Discovery MI DR scanner.  Whole brain radioactivity will be calculated as a percentage of total absorbed dose 

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per kilogram of brain tissue.  Standard uptake values (SUVs), Time activity curves (TACs), and percent variance 
in total radioactivity will be determined and compared at each time point. 
 
 
 
 
Table 3:  Study Measures and Outcomes 
Visit 
1 
2 
3 
Background Measures 
 
 
 
Additional Screening 
X 
 
 
Sociodemographic Measures 
X 
 
 
Tobacco Use History/Dependence 
X 
 
 
NicAlert Test Strip 
X 
 
 
Medical History 
X 
 
 
Abuse Liability 
 
 
 
EC Topography 
 
X 
X 
Drug Effects/Liking Questionnaire  
 
X 
 
Modified Cigarette Evaluation Questionnaire (mCEQ) 
 
X 
 
Tiffany-Drobes Questionnaire of Smoking Urges:  Brief Form (modified) 
 
X 
X 
Minnesota Nicotine Withdrawal Scale 
 
X 
X 
Biomarkers of Exposure/Effect 
 
 
 
Exhaled Carbon Monoxide 
X 
X 
X 
Procedures 
 
 
 
Pregnancy Test 
X 
X 
X 
PET/CT Imaging 
 
X 
X 
  
I. Statistical Methods 
i. 
Power Analysis and Data Analytic Plan 
The present study is a pilot study that will be used for preliminary data for a larger R01 submission.  
Assuming an alpha value of 0.05 and a power of 0.8, a sample size of at least 8 participants is required to 
observe significant differences in the dose released.  As a result, larger populations are likely required in 
order to evaluate a significant difference between the groups.  If the power is set to 0.95 to account for 
this, then the number of participants required per group is 14.  In order to ensure significance and to 
account for any participants that do not comply, a total of 30 participants is required. 
All PET images will be reconstructed to generate quantitative images for absolute determination of 
radioactivity distribution.  Corrections for the decay of [11C] will be applied.  The deposition will be 
shown in 3D and co-localized relative to the anatomy (as provided by the CT images).  The total 
radioactivity will be determined in the head/neck and thorax (e.g., brain, oral cavity, trachea, esophagus, 
bronchi, lungs, and other relevant soft tissues like muscle).  Analysis of other tissues within the imaging 
field of view may be performed if [11C] activity is observed.  The biodistribution, uptake, and clearance 
will be evaluated in the specified tissues.  The results obtained using conventional PET/CT will be 
compared to the results obtained using the new digital technology.  The percent variance in the total 
radioactivity will be determined at each time point for each tissue.  We are not performing intra-

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individual comparator examinations.  We are focusing on assessing the new generation digital 
technology and have comparable historical benchmark data available for comparison.  
 
Each participant will serve as his/her own control. We will plot time-activity curves for the [11C] in the 
lung and brain over the 60-minute scanning period.  For both participant groups, we will compare: 
- 
The lung and brain concentration of [11C] at peak uptake (Cmax for lung and brain). 
- 
The time to peak uptake for the upper and lower lung and whole brain regions (Tmax for upper and 
lower lung and brain). 
- 
The area under the nicotine concentration curve (AUC) for lung and brain regions. 
- 
Puffing topography (puff duration, volume, and flow rate (average and peak) and interpuff interval. 
- 
Demand indices, liking/satisfaction, craving, withdrawal suppression. 
 
For imaging outcomes, topography and subjective effects, all relevant outcome variables will first be 
examined with descriptive statistical analyses that focus on describing and understanding patterns and 
distributions.  We will identify any potential outliers, assess distributional assumptions, and apply 
appropriate transformations if the normality assumption is violated.  To test the impact of pH of e-liquid 
vaped on rate and concentration of [11C]-nicotine uptake in the brain and lung regions, and subjective 
effects, the primary comparison arms will be free-base vs. nicotine salt-based nicotine e-liquid.  For each 
hypothesis we will compare the difference in mean outcomes (post – pre-vaping bout, where 
appropriate) per laboratory session using the mixed effects modeling approach for repeated measures 
analysis of variance that uses a random effects model to account for multiple observations from the 
same study subject’s outcome measures. 
 
Conceptually, the analysis approach reduces to a simple paired t-test for parametric analysis or 
Wilcoxon signed-rank test for non-parametric analysis... This approach allows for proper treatment of 
the multiple observations per study subject’s outcome data by accounting for the correlation of data 
observations within the same study subject’s outcome.  Mixed effects modeling also allows for the 
dataset to have some missing values, unequal time points between subjects, and flexible covariance 
structures..  Pairwise comparisons will be adjusted for multiple testing procedures.  All statistical tests 
will be two-tailed, and no assumptions are made a priori about the direction of potential differences in 
primary outcome distributions. 
 
J. Gender/Minority/Pediatric Inclusion for Research 
i. 
Inclusion of Women and Minorities 
According to U.S. Census Data, 53% of Winston-Salem residents are female.  In our previous studies with 
smokers, 55-62% of participants were female.  In Winston-Salem, racial composition is 56% White, 35% 
Black or African American, 2% Asian, 0.2% American Indian/Alaska Native, 0.1% Native Hawaiian/Other 
Pacific Islander, and 3% two or more races.  The ethnic composition of individuals living in Winston-
Salem is 6% and 15% Hispanic/Latino, respectively.  We expect that our distributions will be similar to 
these but we may potentially have a larger distribution of ethnic and racial minorities, based on our 
team’s previous studies.  However, we will continuously monitor enrollment in order to ensure that we 
are meeting recruitment goals to avoid under-recruiting minorities.  If the targeted enrollment for 
minorities is not met because they do not respond to the advertisements, we will make special efforts to 
solicit their participation by advertising in community newspapers and community centers. 
 

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Version: 4.0 
 
 
ii. 
Inclusion of Children 
Participation in the proposed study will be restricted to individuals 21 years of age and older.  This 
exclusion is because the use of tobacco products by minors is illegal and the concern of introducing and 
potentially addicting children and adolescents to another tobacco product (i.e., electronic cigarettes). 
 
K. Human Participants 
i. 
Potential Risks 
The research protocol calls for current e-cigarette users to use a study e-cigarette.  The participants are 
already using e-cigarettes and will only be asked to use what will be a fully characterized e-cigarette 
device and e-liquids for which an FDA ITP will be submitted and “approved” (i.e., receive an FDA letter of 
“no concern”).  Questionnaires, saliva, and exhaled breath procedures are all non-invasive and involve 
minimal risk to study participants.  Potential risks are as follows: a) risk of using e-cigarettes, b) risk 
associated with radioactivity exposure, c) loss of confidentiality or privacy, and d) lack of appropriate 
storage of nicotine-containing products in a house with children and pets. 
 
ii. 
Protections Against Risk 
a) Recruitment and Informed Consent: 
At first contact, all participants will be screened according to the study’s inclusion/exclusion criteria.  
Those who are eligible will be given a brief verbal overview of the study and invited to participate.  
Informed consent (including a description of the nature, purpose, risks, and benefits of the study) will 
take place through oral explanation of the study.  The voluntary nature of the study and the participant’s 
right to withdraw at any time will be stressed during the consent process.  A copy of the informed 
consent will be provided to the participant in written form at the time of consent for them to keep. 
Informed consent will be collected by IRB-approved study personnel.  The Ohio State University 
Institutional Review Board will approve recruitment script and materials, consent forms, and all study 
procedures.  All participants will provide consent before any study data is collected. 
 
Efforts to reduce risk are as follows: 
a) Risk of using e-cigarettes: The risk of side effects and adverse events are very low.  These products 
are sold online, and at e-cigarette specialty stores and convenience stores nationwide, without a 
prescription.  Nevertheless, all participants will be screened for general medical precautions 
(pregnancy, cardiovascular disease) and monitored for adverse events during the study period.  
Study personnel will assess for adverse events via self-report at all follow-up visits.  Any serious 
adverse events will be reported to the study’s DSMB, then to the Ohio State University IRB, and to 
the NIH.  We will withdraw participants who have a serious adverse event, or become pregnant, 
begin to breastfeed, or have a cardiovascular or pulmonary event during the study.  The most likely 
adverse event (potential for nicotine overdose) is anticipated to be rare (<5% in our team’s previous 
studies) and mild (nausea, headache, disrupted sleep), and will be handled quickly (i.e., advice to 
participant to reduce or stop EC use).  Lab studies of toxin exposure suggest that ECs incur no 
greater risk to health than do conventional cigarettes.  Indeed, e-cigarettes generally show lower 
levels of harmful and potentially harmful constituents.  To date, e-cigarette studies discussing 
adverse events report mild and tolerable side effects that generally resolved completely over time 
with continued use; the most predominant of which were mouth/throat irritation, cough, and 
headache.  In four randomized clinical trials, no serious adverse events were reported and the e-
cigarette group and the nicotine patch group had comparable levels of adverse events in two 

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Version: 4.0 
 
 
studies.  The most common were mouth irritation, throat irritation, dry cough and headache.  
Following the completion of the study, we will encourage all participants to quit their use of e-
cigarettes and they will be provided the number to the North Carolina Tobacco Quitline 
(QuitlineNC). 
 
b) Risk of radiation exposure: The risks of radiation exposure are minimized with the use of a CT scan 
at a very low dose and the lowest dose of [11C]-nicotine (3 mCi) used in a nicotine PET imaging study.   
However, participants’ level of risk from this level of exposure will be explained by giving them a 
comparison to an everyday situation to help them make an informed decision.  Participants will be 
told, “To give you an idea about how much radiation you will get, we will make a comparison with 
an every-day situation.  Everyone receives a small amount of unavoidable radiation each year.  Some 
of this radiation comes from space, and some comes from naturally-occurring radioactive forms of 
water and minerals.  This dosage would give your body the equivalent of about 5 extra months' 
worth of this natural radiation.  A possible health problem seen with radiation exposure is an 
increased cancer risk.  This extra cancer risk is higher at younger ages and for girls and women.  The 
extra lifetime risk of dying of a fatal cancer due to the radiation exposure from this research may 
range from about one in 49,000 to about one in 20,000.  At such low radiation exposures, scientists 
disagree about the amount of risk.  These estimates are very uncertain, and there may be no extra 
risk at all.” 
 
c) Loss of Confidentiality and Privacy: Study subjects’ confidentiality will be maintained at all times. 
Subjects will be assigned a unique study identification number (study ID).  All study data will be 
identified by study ID only.  Any electronic information (e.g., questionnaire data, laboratory data, 
tracking systems, etc.) will only be accessible to authorized study personnel who have the necessary 
password(s).  All computer systems will be password protected against intrusion; all network-based 
inter-site communications of confidential information will be encrypted.  Access to computer-stored 
information will require simultaneous knowledge of the data format, computer language, file name 
and passwords.  Participant information will be accessible only to research staff, who are pledged to 
confidentiality and complete training in the ethical conduct of research (i.e., both HIPAA and CITI 
trainings).  Identifying information will not be reported in any publication. 
 
d) Lack of Appropriate Storage of EC Products: Participants will be instructed to keep their EC 
cartridges up and away from their children and pets to protect against unintentional poisoning.  
Only child-proof e-liquid cartridges will be provided to participants.  Although overdose or accidental 
ingestion is very unlikely and has not occurred in Dr. Wagener’s previous studies, all participants will 
be provided the state and national poison control telephone line as well as a “tip sheet” on 
recognizing signs of nicotine overdose. 
 
iii. 
COVID-19 Considerations 
Assuming COVID-19 is still active in the population at the start of the study, all subjects will follow best 
practices for clinical screening of COVID-19 prior to each visit and on the day of the visit will be in effect 
at Wake Forest.  Participants will be screened prior to arriving on campus for COVID-19 symptoms and 
exposures.  On campus, they will have their temperature taken and required to wear a mask.  Staff will 
wear masks, face shields, gloves and gowns during the study procedures.  If antibody testing is validated 
at any time during the study, this will be incorporated into the screening.  Research staff will follow 
OSU/WF policies by wearing face masks and eye protection, using frequent hand hygiene, and gloves 

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when touching a participant.  Disinfectant policies after each visit also will be followed.  At the start of 
study, and at any time clinical protocols may change, these will be adopted. 
 
iv. 
Potential Benefits of the Proposed Research 
Whereas no assurance can be made to an individual participant that he/she will personally benefit from 
this research, the experience should be beneficial.  In general, this study will provide a benefit to future 
e-cig users as the findings will be reported to public health officials and the FDA to inform policy, both 
for reducing toxicity (if any) and to identify harmful effects.  All participants will be encouraged to quit 
using e-cigarettes at the completion of the study.  Adequate protections are in place in the event of 
unlikely and mild risks for study participation.  Research results will not be returned to the subject.  
Overall, it is expected that the potential benefits to participants in the proposed study outweigh the 
potential risks. 
v. 
Importance of Knowledge to be Gained 
This study is an innovative investigation that will have important public health implications given the 
rapid proliferation of e-cigarettes.  The study has the potential for high public health impact as it will 
provide the scientific foundation, the FDA, and other public health agencies need to establish effective 
regulatory strategies for the manufacture, distribution, and marketing of nicotine salt-based ECs. 
 
L. Data and Safety Monitoring Plan  
 
i. Plan 
Collection of Adverse Events: The collection of adverse events will be on a self-report basis by the 
participant and logged by research staff within an electronic data capture system (REDCap) or collected 
using standardized paper forms and will only be identified with the study’s ID of the participant. All 
Serious Adverse Events will also be reported in OnCore database by Ohio State research staff. 
Adverse Event Reporting Timelines: 
• 
All intervention staff are required to notify the PIs of any Serious Adverse Events 
immediately.  
• 
All Serious Adverse Events will be reported immediately to the medical monitor who will 
determine their severity and appropriate action or response. 
• 
In accordance with current standard procedure, the PIs will notify the Ohio State University 
IRB of all Serious Adverse Events within 24 hours. 
• 
In accordance with new policy and procedure, the PIs will notify the National Institutes of 
Drug Abuse of all Serious Adverse Events within 72 hours.   
• 
All Non-serious AEs will be reviewed weekly by the medical monitor or PI, for categorization 
and possible action.   
Data Safety Management Plan Administration 

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Version: 4.0 
 
 
Adverse Events: All observed or volunteered adverse events regardless of suspected causal relationship 
to study product will be assessed by study staff and recorded on the adverse event page(s) of the 
Adverse Event Form or within an electronic data capture system (REDCap). For the purpose of this study, 
hereafter, Study Product will be used to refer to e-cigarettes.  Events involving adverse Study Product 
reactions or illnesses with onset during the study should be recorded. Exacerbation of pre-existing 
illness is defined as a manifestation (sign or symptom) of the illness that indicates a significant increase 
in the severity of the illness as compared to the severity noted at the start of the trial.  It may include 
worsening or increase in severity of signs or symptoms of the illness, increase in frequency of signs and 
symptoms of an intermittent illness, or the appearance of a new manifestation/complication.  
Exacerbation of a pre-existing illness should be considered when a patient/subject requires new or 
additional concomitant medication or non-medication therapy for the treatment of that illness during 
the trial.  Lack of or insufficient clinical response, benefit, efficacy, therapeutic effect, or pharmacologic 
action should not be recorded as an adverse event.  The medical monitor at Wake Forest University, will 
be responsible for distinguishing between exacerbation of pre-existing illness and lack of therapeutic 
efficacy.  For all adverse events, the PIs will pursue and obtain information adequate both to determine 
the outcome of the adverse event and to assess whether it meets the criteria for classification as a 
Serious Adverse Event requiring immediate notification to the medical monitor.  For all adverse events, 
sufficient information should be obtained by the PIs to determine the causality of the adverse event 
(i.e., Study Product or other illness).  The PIs are required to assess causality and indicate that 
assessment on the Case Report Form.  Follow-up of the adverse event, after the date of therapy 
discontinuation, is required if the adverse event or its sequelae persist.  Follow-up is required until the 
event or its sequelae resolve or stabilize at a level acceptable to the investigator or his/her designated 
representative. 
Serious Adverse Events: All Serious Adverse Events regardless of study product group or suspected 
relationship to Study Medication must be reported immediately to the medical monitor, then to IRB, 
then to NIDA, and in OnCore.  A Serious Adverse Event is any adverse study product experience 
occurring at any dose that: (1) results in death; (2) is life-threatening; (3) results in inpatient 
hospitalization or prolongation of existing hospitalization; (4) results in a persistent or significant 
disability/incapacity; or (5) results in congenital anomaly/birth defect.  Important medical events that 
may not result in death, be life-threatening, or require hospitalization may be considered Serious 
Adverse Events when, based upon appropriate medical judgment, they may jeopardize the 
patient/subject and may require medical or surgical intervention to prevent one of the outcomes listed 
in this definition.  Any Serious Adverse Event or death must be reported immediately independent of 
the circumstances or suspected cause if it occurs or comes to the attention of the principal investigator 
at any time during the study through the last follow-up visit required by the protocol or 30 days after 
the last administration of Study Product, whichever comes later.  Any Serious Adverse Event occurring at 
any other time after completion of the study must be promptly reported if a causal relationship to Study 
Product is suspected.  The only exception to these reporting requirements is Serious Adverse Events that 
occur during a period in which no study product is administered. For all Serious Adverse Events, the 
investigator is obligated to pursue and provide information as requested by the Ohio State University 
IRB in addition to that on the Adverse Event Form.  In general, this will include a description of the 
adverse event in sufficient detail to allow for a complete medical assessment of the case and 
independent determination of possible causality.  Information on other possible causes of the event, 

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including concomitant medications and illnesses, must be provided.  The PIs will ensure that information 
is reported immediately and information entered in the Adverse Event Form are accurate and 
consistent.  
Preventing and Limiting Adverse Events: We will monitor for risk of using e-cigarettes by screening 
participants for general medical precautions.  The most likely adverse event (potential for nicotine 
overdose) is anticipated to be rare and mild based on the PI’s previous studies, and will be handled 
quickly (i.e., advice to participant to reduce or eliminate nicotine use).  Lab studies of toxin exposure 
suggest that e-cigarettes incur no greater risk to health than do combustible cigarettes.  The PIs and 
study personnel will be available for any questions that participants may have about e-cigarettes.  Any 
adverse events, breaks of confidentiality, or any other data or safety issues that arise will be discussed 
immediately between study personnel and the PI. 
 
 

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