Nicotine Reinforcement and Aversion in Young Adult Light Smokers
Phase: EARLY_PHASE1
Conditions: Nicotine Addiction
Sponsor: Yale University

Mehmet Sofuoglu, MD, PhD           Nicotine Reinforcement and Aversion in Young Adult Light Smokers 
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 1.  Principal Investigator: Mehmet Sofuoglu, M.D., Ph.D. 
2. Co-Investigators While all research staff are trained to provide informed consent, those 
identified with an asterisk (*) will provide informed consent for this study. All the research staff 
will have access to the PHI 
Co- Investigator: Suprit Parida, M.D.,  
Nursing Staff: *Ellen Mitchell, RN, Angelina Genovese, R.N., Elizabeth O’Donnell, R.N., 
Maragaret Dion-Markovitz,R.N. 
Research Staff: *Lance Barnes, *Stacy Minnix, BSW, and *Chris Cryan,   
* Michael Stephens 
 
3. Title of Project: Nicotine Reinforcement and Aversion in Young Adult Light Smokers 
4.  Purpose, hypothesis and key questions: 
The proposed study will examine the threshold for nicotine self-administration (NSA) using five 
different nicotine doses in young adult male and female non-dependent smokers (light and 
intermittent smokers or LITS). We propose a double-blind, placebo-controlled study that will 
enroll 195 individuals, targeting a total of 72 completers (36 male and 36 females).  In each of 
the five experimental sessions, smokers will be randomly assigned to one of the five doses of 
nicotine (0.0125, 0.025, 0.05, 0.1 and 0.2 mg/70 kg). The highest dose, 0.2 mg/70 kg, 
corresponds to nicotine delivered by about one or two puffs of a cigarette. At the beginning of 
each experimental session, smokers will sample the assigned both the nicotine dose for that 
experimental session, and the placebo (saline) dose, followed by the opportunity to choose 
between nicotine and placebo for a total of ten choices over a 165-minute period. The main 
outcomes will be threshold dose (the minimum dose of nicotine that is self-administered more 
than placebo) and the slope of dose-response for nicotine self-administration (changes in 
nicotine self-administration per unit change in nicotine dose). We will also collect measures of 
nicotine intake (cotinine), nicotine clearance (3-hydroxycotinine (3-HC) / cotinine), and self-report 
drug effects.  
The following questions will be addressed: 
Aim #1: To assess the threshold reinforcing dose and dose-effect curve for IV NSA at low 
doses in young adult LITS.  
Hypothesis #1A: The threshold reinforcing doses for IV NSA will be between 0.0125 to 0.1 
mg/70 kg. 
Hypothesis #1B: The dose-effect curve for NSA will differ between males and females with 
relatively flat curve in female smokers. 
Aim #2: To assess the threshold and dose-effect curve for the positive and 
negative/aversive subjective effects of IV nicotine at low doses and its relationship to 
nicotine reinforcement.  
Hypothesis #2 A: The threshold for the positive effects will be between 0.0125 to 0.1 mg/70 
kg, for the negative/aversive effect it will be ≥ 0.1 mg/70 kg.  
Hypothesis #2B: Nicotine reinforcement will be positively correlated with the positive and 
negatively correlated with the negative/aversive subjective effects of IV nicotine.   
Exploratory Aims: To examine the influence of nicotine clearance rate on nicotine 
reinforcement threshold and dose-effect curve. 
 

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5. Background: 
Addictive threshold for nicotine 
Similar to other drugs of abuse, cigarette smoking is rewarding (e.g., drug liking or good drug 
effects) and reinforcing (self-administered). Previous studies have shown that smoking a 
cigarette delivers approximately 1 to 1.5 mg of nicotine, inhaled over 10 to 12 puffs (Benowitz 
and Jacob 1984). A group of smokers known as light and intermittent smokers (LITS) or 
‘chippers’, show few or no signs of addiction (Shiffman 1989). Based on the nicotine intake of 
the LITS, it has been suggested that blood cotinine levels over 50 to 70 mg are needed to 
sustain nicotine addiction in smokers (Benowitz and Henningfield 1994). This threshold roughly 
corresponds to a daily intake of 5 mg nicotine or approximately smoking 5 cigarettes/day. Based 
on these figures, Henningfield et al (1998) estimated that the threshold for nicotine 
reinforcement is approximately 0.2 mg of delivered nicotine. As will be summarized below, this 
estimated threshold for nicotine reinforcement has yet to be validated by carefully controlled 
nicotine administration studies.   
Since cigarette smoke contains many other compounds in addition to nicotine and the amount 
of nicotine delivered via smoking cannot be reliably controlled, cigarette smoking is not suitable 
for examining dose-dependent nicotine effects (Hoffmann and Wynder 1986). Pure nicotine 
administration studies, especially via nasal spray, have provided crucial information for the 
threshold doses of nicotine that are reinforcing. Nasal spray provides quicker nicotine delivery, 
compared to nicotine gum or patch, and the amount of delivered nicotine can be reasonably 
controlled (Perkins 2009). In a series of studies, Perkins et al. (1994) have shown that smokers 
and non-smokers can reliably detect the interoceptive stimulus effects of intranasally 
administered nicotine using the drug discrimination procedure. The threshold for nicotine 
discrimination is approximately 3 mcg/kg (0.21 mg for a 70 kg individual) for smokers and 2 
mcg/kg (0.14 mg for a 70 kg individual) for nonsmokers (Perkins et al. 2001). The threshold 
doses for nicotine discrimination are likely lower than the reinforcement threshold since smokers 
are unlikely to find nicotine reinforcing if the dose is below that for which they can detect its 
subjective effects (Perkins 2009). Importantly, smokers did not self-administer nicotine nasal 
spray doses, which were either above or below the threshold for nicotine discrimination, more 
than placebo (6.1 and 7.4, out of 16 choices) (Perkins et al. 2001). This lack of reinforcement 
might be due to the slower rate of nicotine delivery via spray, which does not match the rapid 
nicotine delivery via smoking. Thus, although the nicotine discrimination studies with nasal 
spray provide crucial information for the threshold of the interoceptive stimulus of nicotine, the 
threshold for nicotine reinforcement remains to be determined using more rapid delivery 
systems. 
Dose-response curve for nicotine reinforcement 
Characterization of the dose-response curve of a drug provides crucial information including the 
minimum effective or threshold dose as well as the shape and slope of the dose-response 
curve. While the shape of the dose-response curve indicates how the response changes at 
different dose levels (e.g., linear, U-shaped, or flat), a higher slope indicates greater response to 
dose increases (i.e., greater sensitivity). The dose-response curve for IV nicotine self-
administration has been well characterized in preclinical studies (Corrigall et al. 2000; Donny et 
al. 2000; Fattore et al. 2002; Le Foll et al. 2007; Rose and Corrigall 1997). The typical pattern of 
nicotine self-administration behavior that has emerged from many preclinical studies is that the 
dose-dependent changes in drug use behavior are restricted to low and high dose ends of the 
dose-response curve, while the middle range is relatively insensitive to changes in nicotine 
doses (Rose and Corrigall 1997). Consistent with these findings, in our previous study with IV 
nicotine self-administration, we observed no change in nicotine self-administration between 0.4 
and 0.7 mg of nicotine (Sofuoglu et al. 2008a). A similar insensitivity of smoking behavior has 
been observed when nicotine intake is experimentally manipulated (Benowitz and Jacob 1990). 

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Further characterization of the dose-response curve for nicotine reinforcement remains to be 
examined using rapid and accurate nicotine delivery systems. 
IV nicotine administration 
We propose to use IV NSA to determine the threshold for nicotine reinforcement due to its 
advantages over other routes of pure nicotine. First, the IV route produces fast nicotine delivery 
with peak plasma levels reached in 20 sec, which is comparable to smoking (Rose et al. 2003; 
Zins et al. 1997). Second, IV nicotine provides accurate dosing by delivering nicotine directly 
into the circulation and bypassing the absorption step, which shows significant individual 
variation. Third, IV nicotine is reinforcing in rodents, primates, and humans. Rats and monkeys 
self-administer IV nicotine (Corrigall et al. 2000; Donny et al. 2000; Fattore et al. 2002; Le Foll et 
al. 2007; Rose and Corrigall 1997). In humans, when administered rapidly (i.e., in less than 60 
sec), IV nicotine elicits pleasurable subjective effects such as “good effects” and “drug liking” 
similar to those elicited by smoking and is self-administered by smokers (Harvey et al. 2004; 
Henningfield and Goldberg 1983; Henningfield et al. 1983). Thus, the rapid and accurate dose 
delivery, combined with reinforcing effects, makes IV nicotine an optimum route to examine the 
threshold for nicotine reinforcement. 
A critical issue in IV NSA studies is the dose of nicotine. In the Harvey et al (2004) study, male 
smokers preferred nicotine injections over saline-administration for 0.75, 1.5, or 3.0 mg/injection 
of nicotine doses. These nicotine doses, however, are much higher than the typical nicotine 
intake of an average smoker, which is 1-4 mg nicotine/hour (Benowitz and Jacob 1990). To 
address this limitation, in a recent study, we examined self-administration of nicotine doses 
within the range of average intake by smokers (Sofuoglu et al. 2008a). We used a choice 
procedure in which male and female smokers were able to choose between various IV nicotine 
doses (0.1, 0.4, and 0.7 mg) or saline. Both the 0.4 and 0.7 mg/70 kg, but not the 0.1 mg, doses 
were preferred over placebo. In a more recent study, we examined self-administration of lower 
doses of nicotine (0.1, 0.2, 0.3 or 0.4 mg) using a more rapid, 30 sec, delivery rate 12 male and 
14 female smokers (34). NSA was negatively correlated with nicotine dose in males who 
displayed choice preference for lower doses (0.1 and 0.2 mg doses) of nicotine over the highest 
tested dose (0.4 mg). However, no significant relationship between dose and choice preference 
was evident in females. The 0.1 and 0.2 mg nicotine doses also produced positive subjective 
effects, suggesting that nicotine reinforcement threshold is equal or less than 0.1 mg. To our 
knowledge, the dose-effect curve of nicotine in doses less than 0.1 mg has not been examined 
in humans.    
Proposed Study 
Although the presumption of an addictive threshold dose of nicotine is one of the pillars of 
nicotine reduction strategies, it has yet to be characterized in well-designed human studies. This 
project will address this gap by assessing the threshold and dose-effect curve for NSA over a 
low dose range that is expected to capture the reinforcement threshold. It is likely that the 
nicotine reinforcement threshold will display inter-individual differences. Older and dependent 
smokers, compared to young adult LITS, may likely have higher reinforcement threshold due to 
tolerance to nicotine’s behavioral effects as a result of long-term nicotine intake. We chose 
young adult LITS given that the threshold for addictive doses of nicotine was estimated based 
on the nicotine intake of LITS. As suggested by previous findings from our, and other research 
groups, male and female smokers may differ in their sensitivity to the behavioral effects of 
nicotine. In addition, there is evidence to suggest that the rate of nicotine clearance may affect 
nicotine dose-effect curve and reinforcement threshold. Therefore, the influences of both gender 
and nicotine clearance rate [assessed by the ratio of hydroxycotinine/cotinine or otherwise 
known as the nicotine metabolite ratio (NMR)] will be examined in this application. This project 
will also examine the relationship between NSA and the positive and negative/aversive 
subjective effects of IV nicotine.  

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These subjective measures are important because evidence suggests that while positive drug 
effects are associated with abuse liability and drug intake, sensitivity to the negative/aversive 
subjective effects of nicotine may prevent both the initiation of tobacco product use and the 
amount of nicotine intake in established tobacco users. Accordingly, nicotine reinforcement may 
be a function of the relative balance between nicotine’s positive and negative/aversive effects. 
However, to what extent the individual’s sensitivity to the negative/aversive effects of nicotine 
changes the threshold and dose-effect function for nicotine reinforcement has not been 
determined. Identifying factors that affect the reinforcement threshold of nicotine will be an 
important step in developing science-based policies for reducing nicotine in tobacco products.  
Preliminary Studies  
Study 1: Sex differences in nicotine self-administration of low doses of nicotine in smokers.  
Aim: The goal of this study was to investigate the dose-response function for the reinforcing 
and subjective effects of intravenous (IV) nicotine in male and female smokers using nicotine 
doses that are estimated to be delivered by smoking one or two puffs of cigarettes.  
Method: Twenty-six smokers (12 male and14 female) participated in a double-blind, 
placebo-controlled, crossover study that included 4 experimental sessions. In each session, 
participants were randomly assigned to one of 4 doses of nicotine (0.1, 0.2, 0.3 or 0.4 mg). In 
each session, subjects first received the sample infusions of the assigned nicotine dose and 
placebo and then had the opportunity to choose between nicotine and placebo for a total of 6 
choices spaced evenly over a 90-minute period. The main outcome measures were the number 
of nicotine choices, self-report drug effects and physiological responses.  Results: A sex-by-
dose interaction was observed in the nicotine choice paradigm (Fig 1). Nicotine self-
administration rate was negatively correlated with nicotine dose in males (males displayed 
choice preference for low doses of nicotine over high doses of nicotine), but no significant 
relationship between dose and choice preference was evident in females. Overall, the number 
of nicotine choices was not greater than saline choices (p>0.05).  
Figure 1. The mean (± SEM) nicotine 
infusion number (maximum 6) for male 
(n=12) and female (n=14) subjects at each 
dose is shown. Nicotine self-administration 
frequency was negatively correlated with 
nicotine dose among males but not females 
(dose by sex p < 0.05). Post hoc 
comparisons showed that both 0.1 and 0.2 
mg doses were self-administered more than 
the 0.4 mg nicotine doses. 
 
 
 
 
 
 
 
 
 
 

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Figure 2. Subjective 
ratings of the pleasurable 
and aversive effects of 
intravenous nicotine in 
smokers. Shown is the 
mean value (± SEM) for 6 
post-infusion ratings of 
drug effects for subjects 
(n=26). The subjective 
ratings for nicotine are 
relative to the ratings for 
saline, using the DEQ with 
a scale of 0-10.   
Further, all nicotine doses 
(0.1, 0.2, 0.3, 0.4 mg) were rated as more pleasurable than saline (Figure 2). The aversive 
effects were significantly higher relative to saline in response to nicotine at 0.3 mg, but not at the 
other nicotine doses. 
Conclusions: Among males, low doses of IV nicotine were preferentially chosen over high 
doses of nicotine. In contrast, among females no dose-sensitive choice preference was 
observed. The IV nicotine doses also induced subjective ratings of positive and negative drug 
effects that differed from saline. Notably, all doses tested, including the lowest tested dose (0.1 
mg) were rated as more pleasurable than saline by both sexes, indicating abuse potential for all 
tested doses, although the number of nicotine choices were not greater than those for saline. 
This discrepancy could be due to the small sample size and the relatively few opportunities to 
self-administer nicotine at each dose (up to 6 choice trials per dose). These limitations will be 
addressed in the current study. 
The dose-dependent sex differences in reinforcement behavior and the dose-dependent 
changes in positive and negative subjective ratings of drug effects are relevant to dependence 
vulnerability. These findings, which demonstrate sex differences in NSA for doses that are near 
to the reinforcement threshold, suggest that male and female smokers may respond differently 
to changes in nicotine doses available for self-administration. The negative correlation between 
nicotine dose and self-administration suggests partial compensation in males.  
Study 2: Higher 3-hydroxycotinine (3-HC)/cotinine is associated with greater reward and 
heart rate increases from intravenous nicotine: In previous studies, high nicotine metabolite 
ratio (3-HC/cotinine) predicted poor outcomes for smoking cessation treatment with nicotine 
patch. The underlying mechanisms that associate metabolite ratio with treatment outcomes 
have not been fully elucidated. A total of 100 smokers were divided into quartiles based on 
their baseline plasma nicotine metabolite ratio. Following overnight abstinence, smokers 
received saline followed by escalating intravenous doses of nicotine (7 and 14 mcg/kg) 
given 30 min apart.  Smokers in the first quartile (slower metabolizers) had lower FTND 
scores, suggesting lower levels of dependence. In contrast, smokers in the fourth quartile 
(faster metabolizers) reported greater craving for cigarettes following overnight abstinence 
from smoking and reported greater ratings of nicotine-induced good drug effects, drug liking, 
and wanting more drug. Higher nicotine metabolite ratio was also associated with greater 
heart rate increases in response to nicotine. These results suggest that nicotine metabolite 
ratio may influence the subjective rewarding and physiological effects from nicotine and 
withdrawal severity.  
 
 

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In summary, our previous work demonstrates the feasibility of IV nicotine self-administration to 
determine the reinforcement threshold for nicotine in LITS. Our findings point to a range of 
nicotine doses, 1.5 to 6.0 mcg/kg, that is well-tolerated by non-dependent smokers and can be 
used to determine the reinforcement threshold. Our group has unique expertise and a track 
record in conducting IV nicotine administration studies in both male and female smokers. 
6. Significance: 
The proposed study is highly significant. First, this study will be especially informative in 
determining the threshold doses of nicotine needed to maintain nicotine self-administration in 
male and female LITS smokers. Characterization of the shape and slope of dose-response 
curves for the reinforcing effects of IV nicotine will help to accurately determine how male and 
female smokers adapt their nicotine self-administration to reductions in nicotine doses that are 
available. Whereas the actual threshold and dose-response function may differ in cigarette 
smoke-delivered nicotine, the IV self-administration data should contribute to a better 
understanding of the potential threshold and dose-response function for nicotine reinforcement 
in general. Second, the proposed study will likely foster further preclinical and clinical research 
on nicotine reinforcement and its moderation by sex. Since the IV route is commonly used for 
nicotine self-administration studies in rodents and primates (Le Foll et al. 2007), findings from 
our study will allow translational comparisons of threshold and dose-response curves for 
nicotine reinforcement between human and animal studies. Finally, the goals of this proposal 
are also highly relevant to the FDA’s new mission of setting standards for the evaluation of new 
tobacco products as well as the risks of initiation and dependence and consistent with the 
recommendations of the World Health Organization (WHO) for further evaluation of the 
importance of nicotine in the appeal, addiction potential, and harmful effects of cigarette 
smoking (WHO, 2007). Ultimately, the result of this study may provide information that is crucial 
for the development of science-based policies to control the addictive potential of cigarette 
smoking for both male and female smokers.   
7. Subjects: 
Inclusion criteria: 1) Female and male smokers, aged 18 to 35 years, who have been smoking 
for at least a year, and a life-time consumption of at least 100 cigarettes; 2) smoke more 
frequently than once a week and ≤5 cpd; 3) FTND score <3 indicating no or minimal evidence 
for nicotine dependence; 4) urine semi-quantitative cotinine levels >100 ng/mL indicating an 
active smoking status; 5) not seeking treatment at the time of the study for nicotine dependence; 
6) in good health as verified by medical history, screening examination, and screening 
laboratory tests; 7) for women, not pregnant as determined by pregnancy screening, nor breast 
feeding, and using acceptable birth control methods.    
Exclusion criteria: 1) history of major medical illnesses that the physician investigator deems as 
contraindicated for the subject to be in the study; 2) requirement of any form of regular 
psychotropic medication (antidepressants, antipsychotics, or anxiolytics) or psychiatric 
diagnosis and treatment for psychiatric disorders including major depression, bipolar disorder, 
schizophrenia in the past 6 months; and 3) current dependence to alcohol or any other 
recreational or prescription drugs and; 4) daily use of smokeless tobacco products or exclusive 
daily use of e-cigarettes (non-daily users will be included).  
Justification for age criteria: The study will enroll young adults between the ages of 18 to 35 
because this age group represents a critical time for development of nicotine addiction, with 
almost all progression to daily smoking completed by the age of 26.   
 
 
 

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Stratified sampling procedure for race and presence of daily smoking: The study will enroll 36 
male and 36 female LITS. The two groups will be matched on race and presence of daily 
smoking. Race has been shown to influence smoking behavior and nicotine pharmacokinetics. 
We will create a race variable (0= Caucasian, 1= African-American, 2=Other) to match groups 
on race. We will also stratify for the presence of daily smoking because daily smoking may 
influence the behavioral effects from smoking by tolerance development (9-11). This approach 
will allow balancing the male and female smokers for light vs. intermittent smokers. A 
categorical variable will be created for the presence of daily smoking (1= present, and 0 = 
absent). 
9. Selection:  
Male and female smokers will be recruited from the New Haven area through newspaper 
advertisements and fliers. We will recruit both veterans and non-veterans since there are not 
enough veterans in our area who meet the inclusion criteria for the study.  Interested subjects 
will have the study described over the telephone and will be asked to answer a brief tobacco 
use history and medical screening questionnaire. If subjects are eligible for the study based on 
the telephone screening, they will then be invited to come to the clinic for an initial screening 
evaluation. The initial screening evaluation will include the following: a) obtaining an informed 
consent; b) smoking history and assessment of nicotine dependence based on the Fagerstrom 
Test of Nicotine Dependence (FTND); and c) a urine semi-quantitative cotinine level to confirm 
active smoking status at study entry.. 
If subjects are eligible based on the stratification procedure, they will be invited to participate in 
a second evaluation, which will include: a) complete physical and psychiatric examination 
including the structured clinical interview (SCID) for DSM-V; b) laboratory examination including 
CBC, ALT, AST, alkaline phosphatase, glucose, BUN, creatinine c) DNA; d) urine analysis, drug 
screening, and for women, urine pregnancy test. The laboratory test results will be part of the 
patients’ medical record at the VA Hospital located on the CPRS system, as well as in the 
subject’s research chart; and e) ECG.  
10: Recruitment:  
A total of 300 subjects will be enrolled, targeting 72 completers (36 males and 36 females) 
under the new study design. To date (April 2016), 45 subjects have signed consents with 23 
completers under the previously approved protocol design. These subjects will not be asked to 
return for participation in the new study design.  
11. Research Plan: 
A. Overview 
This will be a double-blind, placebo-controlled study, with 72 LITS (36 male and 36 female 
smokers) participating in five experimental sessions.  All sessions will be conducted following 
overnight abstinence to control for recent nicotine intake. The lab sessions will be at least 24 
hours apart to minimize carryover nicotine effect between sessions In each experimental 
session, subjects will be randomly assigned to one of the five doses of nicotine (0.0125, 0.025, 
0.0.5, 0.1 and 0.2 mg/70 kg or about 0.18, 0.36, 0.7, 1.4 and 2.8 µg/kg). At the beginning of 
each experimental session, subjects will first sample the assigned nicotine dose and placebo 
(saline) condition that are randomly labeled as A or B. Beginning 15 minutes after the second 
sample dose, subjects will have the opportunity to choose between drug A or B every 15 
minutes, for a total of ten opportunities over a 165-minute period. Immediately after subjects 
make their choice, drugs will be administered over 30 seconds using an infusion pump. The 
main outcome measure will be the number of nicotine self-administrations for each nicotine 
dose. The parameters of this nicotine self-administration procedure were based on our previous 
study (Sofuoglu et al. 2008a). 
 

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B. Medical Monitoring and Safety 
Subjects will be given a thorough physical examination prior to entry in the study. For nicotine 
administration sessions, a physician will be present and subjects will be attached to a cardiac 
monitor as well as a blood pressure and heart rate monitoring device. An IV catheter will be in 
place throughout the session. Subjects will be administered nicotine only if the systolic blood 
pressure is <150 mmHg and heart rate is <100 beats/minute. Subjects will be terminated from 
the study if the blood pressure at any time is >170/110 mm Hg, the heart rate is >120 beats/min, 
or if they develop signs and symptoms compatible with nicotine toxicity. Subjects will remain in 
the laboratory for at least an hour after the last nicotine administration. These procedures have 
been developed as part of our IND for IV nicotine.  
C. Outcome Measures  
Behavioral 
Nicotine Self-Administration: Nicotine self-administration behavior will be measured with the 
number of nicotine administrations during the session. 
Physiological 
Heart rate and blood pressure: Heart rate and blood pressure readings will be taken at intake for 
screening, and during the lab sessions to monitor nicotine’s effects.  
Biochemical 
1) Alveolar carbon monoxide: The CO measurement taken before the sessions will help to verify 
compliance with smoking abstinence. CO readings ≤ 8ppm will be used to verify compliance 
with overnight smoking as recommended by the SRNT Subcommittee on Biochemical 
Verification (Benowitz et al. 2002).  
2) Serum estradiol and progesterone analysis (females only): Serum estradiol and progesterone 
levels will be measured before each lab session for use as covariates in our analysis, since 
female sex hormones may contribute to sex differences in nicotine responses (Smith et al. 
2006; Sofuoglu et al. 2001; Zubieta et al. 2002).  
4) Plasma/urine cotinine, 3-hyroxycotinine (3-HC), and nicotine levels: Plasma/urine samples of 
cotinine will be taken at intake to quantify the level of nicotine intake of the subjects. 3-HC is the 
main metabolite of cotinine and the ratio of 3-HC/cotinine, also known as the nicotine metabolite 
ratio, reflecting the activity of cytochrome P450 (CYP2A6) and thus, the rate of nicotine 
clearance.  Plasma nicotine levels will also be measured before each session to ensure 
overnight abstinence from smoking. Assays for nicotine, cotinine, and 3-HC levels will be 
performed in Dr. Peter Jatlow’s laboratory. Briefly, nicotine, cotinine and 3-HC are measured 
using HPLC coupled to tandem mass spectrometry (LC/MS/MS) employing stable isotope 
labeled internal standards as previously described. 
Subjective 
Intake Measures:  
1) Structured Clinical Interview for DSM-5 (SCID) for Axis I disorders: SCID is a semi-structured 
interview based on DSM-5 (American Psychiatric Association, 2013) and will be performed to 
diagnose Axis I psychiatric disorders.  
2) Fagerstrom Test of Nicotine Dependence (FTND): This self-report measure assesses the 
degree of nicotine dependence and has been used widely in smoking studies (Heatherton et al. 
1991) 

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 3) Center for Epidemiologic Studies Depression (CES-D) scale: The CES-D is a 20-item self-
report measure of depressive symptoms (Radloff 1977). This scale will be used at intake to 
control for baseline differences in depressive symptoms. 
Session Measures: 
1) Minnesota Nicotine Withdrawal Symptom Checklist (M-NWSC): Smokers will be asked to rate 
several nicotine withdrawal symptoms from on a 100 mm scale, "not at all" to "extremely." The 
items are derived from the M-NWSC (Hughes and Hatsukami 1986) and have been used in 
previous human laboratory studies (Eissenberg et al. 1996). The items include cigarette craving, 
irritability/anger, anxiety/tension, difficulty concentrating, restlessness, increased appetite, 
depressed mood, and insomnia.  
2) Positive and Negative Affect Schedule (PANAS ): The PANAS is a 20-item scale that 
assesses both negative and positive affective states (Watson et al. 1988). This scale is sensitive 
to the affective symptoms of tobacco withdrawal and predicts relapse to smoking (Kenford et al. 
2002).  
3) Brief Questionnaire on Smoking Urges (BQSU): This 10-item scale has been found to be 
highly reliable and reflects levels of nicotine deprivation (Bell et al. 1999; Morgan et al. 1999). 
This scale will be used to monitor cigarette craving.  
4) Drug Effects Questionnaire (DEQ): Smokers will rate 5 items that are related to nicotine effect 
on a 100 mm scale, "not at all" to "extremely." The items are feeling the “drug strength,” feel 
“good” drug effects, feel “bad” drug effects, liking the drug effects, and “head rush.” This 
instrument allows rapid detection of nicotine effects and is adapted from a VAS (Soria et al. 
1996).  
Genetics 
Blood samples for DNA extraction will be collected to examine whether any of the genes modify 
the effects of nicotine. Candidate genes will be selected from a list of genes hypothesized to be 
involved in nicotine’s effects. The current list of genes includes but is not limited to genes for 
nicotinic and muscarinic receptors. To protect confidentiality, each subject’s blood sample will 
be encoded with a numeric designation and the name of the individual will be stored in a 
separate database. The samples will be transferred to the Genetic Laboratory at the VA medical 
Center for processing and storage.   
D. Drugs 
Nicotine: Nicotine bitartrate will be obtained from Interchem Corporation, Paramus, NJ. 
Nicotine solution for injection will be prepared by U.S. Specialty Formulations, Bethlehem, 
P.A.. Nicotine increases heart rate, peripheral vascular resistance, myocardial contractility, 
cardiac output, and blood pressure. Nicotine may cause nausea, vomiting, and diarrhea. 
Acute toxicity of nicotine occurs with high doses; 40-60 mg orally is considered lethal. Signs 
and symptoms of acute toxicity include nausea, vomiting, abdominal pain, hypersalivation, 
diarrhea, dizziness, confusion, hearing and vision problems, syncope, seizures, hypotension, 
irregular pulse, and death (Benowitz and Gourlay 1997; Kobayashi et al. 1999).  
 
 
 
 
 
 
 

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Nicotine administration: In our proposed study, nicotine will be administered over 30 seconds, 
via an IV catheter located in a forearm vein, using an infusion pump. We have followed these 
procedures in our previous studies (Sofuoglu et al. 2003, 2005, 2006b; 2008a, 2009a, b,c; 
Sofuoglu and Mooney 2009), which were completed without any adverse effects or safety 
concerns. For each experimental sessions, two IV infusions will be prepared in randomized, 
double-blinded fashion. The two infusions will be marked as either “A” or “B” on identical-
looking IV labels. Depending on the randomization, one of the infusion will contain an active 
nicotine dose (0.0125, 0.025, 0.05, 0.1 and 0.2 mg/70 kg) and the other will contain saline. 
The total amount of nicotine solution in the active infusion will contain enough for 1 sample 
dose of 5 mL, 10 optional doses of 5mL each, and additional volume to prime the infusion line. 
The matching placebo infusion will also contain enough for 1 sample dose of 5mL, 10 optional 
doses of 5mL each, and additional volume to prime the infusion line.  
 
The matching placebo infusion bags will also contain enough for 1 sample dose and 10 
optional doses and for the line flush of 0.9% NaCl.  The infusion bags will be labeled and 
dispensed to the study staff by the research pharmacy. Dr. Sofuoglu holds an IND for IV 
nicotine administration. 
Justification for the nicotine doses: For this proposal, we chose five doses of nicotine that are 
in low dose range including 0.0125, 0.025, 0.05, 0.1 and 0.2 mg/70 kg. The highest dose, 0.2 
mg, is equivalent to the amount of nicotine delivered from one or two puff of a cigarette, which 
ranges from 0.05 to 0.2 mg/puff or 0.5 to 2.4 mg/cigarette 1.0 - 2.4 mg, delivered via 10 to 13 
puffs (33, 81, 82). In our previous study, 0.2 mg/70 kg dose of nicotine produce positive 
subjective drug effects and were self-administered by male dependent smokers (34). The 
lowest dose will be 0.0125 mg/70 kg, lower than the amount estimated to be the addictive 
threshold for nicotine by B&H, 0.17mg nicotine/cigarette or 0.014 mg nicotine/ puff. We also 
included 3 additional doses of nicotine 0.025, 0.05, 0.1 mg, in between the 0.2 and the 0.0125 
mg dose to provide a more detailed assessment of dose-effect function. These five doses of 
nicotine and placebo should allow for a detailed examination of individual differences in NSA 
at a low dose range 
E. Study Procedures 
Session procedures: Before the test sessions, smokers will be required to abstain from smoking 
for 10 h, which will be verified by expired air CO levels ≤8 ppm (Benowitz et al. 2002). Subjects 
will be asked to refrain from consuming alcoholic beverages and drugs during study 
participation, which will be verified by a urine drug quick test. If results indicate non-compliance 
with these study procedures, subjects will be discharged from the study. Subjects will be 
instructed to drink their typical amount of caffeinated beverages in the morning to minimize 
caffeine withdrawal, which could confound the study measures. Subjects will be instructed not to 
eat for four hours before the lab sessions to reduce the chance of vomiting.  A light lunch will be 
provided at the end of each experimental session.  
Medical monitoring: Subjects will be given a thorough physical examination prior to entry in the 
study. For nicotine administration sessions, a physician will be present and subjects will be 
attached to a cardiac monitor as well as a blood pressure and heart rate monitoring device. An 
IV catheter will be in place throughout the session. Subjects will be administered nicotine only if 
the systolic blood pressure is <150 mmHg and heart rate is <100 beats/minute. Subjects will be 
terminated from the study if the blood pressure at any time is >170/110 mm Hg, the heart rate is 
>120 beats/min, or if they develop signs and symptoms compatible with nicotine toxicity. 
Subjects will remain in the laboratory for at least an hour after the last nicotine administration. 
These procedures have been developed as part of our IND for IV nicotine.  
 
 

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TABLE 1. SCHEDULE OF EVENTS: EXPERIMENTAL SESSION*   
Minutes  
Time point Measures and Events 
0 Min 
1 
HR/BP, DEQ, IV nicotine or saline administration A (sampling) CO, HR/BP, EKG, M
1 Min 
2 
HR/BP, DEQ 
2 Min 
3 
HR/BP,  
3 Min 
4 
HR/BP, DEQ 
5 Min 
5 
HR/BP, DEQ   
15 Min 
6 
HR/BP, DEQ  I V nicotine or saline administration B 
16 Min 
7 
HR/BP, DEQ  
17 Min 
8 
HR/BP 
18 Min 
9 
HR/BP, DEQ  
20 Min 
10 
HR/BP, DEQ  
30 Min 
11 
HR/BP, DEQ  IV Choice Sampling  Option 1 
31 Min 
12 
HR/BP, DEQ  
32 Min 
13 
HR/BP 
33 Min 
14 
HR/BP, DEQ  
35 Min 
15 
HR/BP, DEQ  
45 Min  
16 
HR/BP, DEQ  IV Choice Sampling Option 2 
46 Min 
17 
HR/BP, DEQ  
47 Min 
18 
HR/BP 
48 Min 
19 
HR/BP, DEQ  
50 Min 
20 
HR/BP, DEQ  
60 Min 
21 
HR/BP DEQ IV sampling Option 3 
61 Min 
22 
HR/BP, DEQ  
62 Min 
23 
HR/BP 
63 Min 
24 
HR/BP, DEQ  
65 Min 
25 
HR/BP, DEQ  
75 Min 
26 
HR/BP, DEQ  IV sampling Option 4 
76 Min 
27 
HR/BP DEQ 
77 Min 
28 
HR/BP,  
78 Min 
29 
HR/BP, DEQ  
80 Min 
30 
HR/BP , DEQ 
90 Min 
31 
HR/BP, DEQ IV sampling Option 5 

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91 Min 
32 
HR/BP DEQ 
92 Min 
33 
HR/BP,  
93 Min 
34 
HR/BP, DEQ  
95 Min 
35 
HR/BP, DEQ 
105 Min 
36 
HR/BP, DEQ IV sampling Option 6 
106Min 
37 
HR/BP DEQ 
107Min 
38 
HR/BP,  
108 Min 
39 
HR/BP, DEQ  
110 Min 
40 
HR/BP, DEQ 
120 Min 
41 
HR/BP DEQ IV sampling Option 7 
121 Min 
42 
HR/BP DEQ 
122 Min 
43 
HR/BP,  
123 Min 
44 
HR/BP, DEQ  
125 Min 
45 
HR/BP, DEQ 
135 Min 
46 
HR/BP DEQ IV sampling Option 8 
136 Min 
47 
HR/BP DEQ 
137 Min 
48 
HR/BP,  
138 Min 
49 
HR/BP, DEQ  
140 Min 
50 
HR/BP, DEQ 
150 Min 
51 
HR/BP DEQ IV sampling Option 9 
151 Min 
52 
HR/BP DEQ 
152 Min 
53 
HR/BP,  
153 Min 
54 
HR/BP, DEQ  
155 Min 
55 
HR/BP, DEQ 
165 Min 
56 
HR/BP DEQ IV sampling Option 10 
166 Min 
57 
HR/BP DEQ 
167 Min 
58 
HR/BP,  
168 Min 
59 
HR/BP, DEQ  
170 Min 
60 
HR/BP, DEQ 
180-240 Min  61 
HR/BP, DEQ, EKG, SCF M-NWSC, BQSU, PANAS, SNACK and Discharge 
 
 
 
 
 
 

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*Same measure will be obtained following saline and each nicotine administration. For brevity, 
only the measures after saline are shown.  
Abbreviations: CO: Alveolar carbon monoxide, HR/BP: Heart rate/Blood pressure; EKG: 
Electrocardiogram; SCF: Symptom Checklist form; M-NWSC: Minnesota Nicotine Withdrawal 
Symptom Checklist; BQSU: Brief Questionnaire of Smoking Urges; PANAS: Positive and 
Negative Affective Schedule; DEQ: Drug Effects Questionnaire. 
Experimental sessions: The schedule of events during the experimental sessions is shown in 
Table 1. Before the session begins, subjects will have an IV catheter placed and the baseline 
measures will be taken. Subjects will begin NSA as described below.  
Nicotine self-administration procedure: 
Apparatus: Saline and nicotine will be administered with two separate infusion pumps, which will 
be prepared with IV infusion bags randomly labeled as Drug A or B by the research pharmacist. 
Both the researchers and the subjects will be blind to the randomization. The infusion pumps 
will deliver saline and nicotine at a precise rate and volume.    
 
 
Procedure: The NSA procedure will consist of two phases: Sampling and Nicotine Choice. 
Sampling: In each of the five test sessions, subjects will be randomly assigned to one of the five 
doses of nicotine: 0.0125, 0.025, 0.05, 0.1 and 0.2 mg/70 kg. Subjects will first receive saline and 
the assigned nicotine dose in a randomized order and double-blind fashion. Subjects will be 
informed that they will be receiving drug A or B, which may be nicotine or saline. This procedure 
will allow subjects to sample the nicotine and saline that will be available during that session. In 
addition, subjective and physiological responses to the sample nicotine dose and saline will be 
assessed.  
Nicotine Choice procedure: Beginning 15 minutes after the sampling phase is completed, subjects 
will be asked to make a choice between drug A or B every 15 minutes for a total of ten choices 
over 150  minutes. The drug chosen by the subjects will be immediately delivered with the infusion 
pump over 30 sec in 5 ml of saline. This choice procedure has been used in our IV nicotine self-
administration study as well as in many previous studies with various drugs of abuse (Sofuoglu et 
al. 1999, 2000, 2001; 2009c). One particular advantage of this model, compared to the ad lib 
models used in previous IV nicotine self-administration studies (Harvey et al. 2004; Rose et al. 
2003), is the ability to control amount of nicotine delivered without interfering with the self-
administration behavior.  
12. Data analysis methods: 
Data analyses: The primary analyses will be intent-to-treat and will include all available data on 
subjects who complete at least one test day. Mixed-effects models will be used to test the study 
hypotheses. These models allow for different numbers of observations per subject, use all 
available data on each subject, and are unaffected by randomly missing data. They also provide 
flexibility in modeling the correlation structure of the data. All data will be checked for normality 
and transformations will be applied as necessary. Significance level of 0.05 will be used for the 
main hypotheses and Bonferroni correction will be applied for post-hoc tests and secondary 
analyses.  
Specific Aim #1: Aim #1: To assess the threshold reinforcing dose and dose-effect curve for 
IV NSA at low doses in young adult LITS. Hypothesis #1A: The threshold reinforcing doses for 
IV NSA will be between 0.0125 to 0.05 mg/70 kg. Hypothesis #1B: The dose-effect curve for 
NSA will differ between males and females with relatively flat curve in female smokers. 

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Aim #1 Analysis: The reinforcing effects of nicotine will be determined by the number of IV 
NSAs in each session, ranging from 0 to 10. The threshold dose for NSA will be determined by 
the lowest dose of nicotine for which the number of NSAs is significantly greater than those for 
placebo (saline) (i.e., proportion of NSA significantly higher than 0.5). For assessing the dose-
response relationship, the parameters of interest will be the slope and shape of the dose-
response curve. The slope indicates the degree to which self-administration changes with an 
increase in nicotine dose (in other words, sensitivity of NSA to changes in nicotine dose).   
The analysis of Aim #1 will conducted in several steps. First, we will use descriptive 
statistics and figures to summarize the data. In particular, the number of NSAs for each dose of 
nicotine will be plotted individually, for the entire sample, and for male vs. female and smokers. 
This step will allow a visual inspection of both individual and group differences for estimating the 
threshold dose and the shape of the dose-response curve for nicotine reinforcement. Second, 
we will fit mixed effects logistic regression models with the proportion of NSAs per session (out 
of 10) as the dependent variable, dose as a fixed categorical predictor and subject as a random 
effect. This approach allows us to take into account the correlations between repeated 
observations on the same individual and to estimate individual deviations from the overall group 
thresholds.  
It also does not assume a specific form of the dose-response relationship and allows us to 
use all available data on a subject in the unlikely event that a subject fails to complete a 
session. If a subject fails to complete a session, the total possible number of self-administrations 
for this subject and session will be adjusted.  
We expect to observe a significant dose effect and will compare the proportion of NSAs at 
each dose to 0.5 across subject groups. The lowest nicotine dose that has a significantly higher 
proportion of NSA than 0.5 will be selected as the threshold dose (Hypothesis 1A). To assess 
the dose-response relationship in the preference for nicotine, polynomial effects of dose (linear, 
quadratic, cubic) and change-point linear models will be tested in the mixed effects logistic 
regression model. We anticipate that there will be a significant linear relationship between dose 
and response rate at lower doses with flattening of the relationship at higher doses. We will use 
the slope of the dose effect to assess the linear dose effect. Alternative non-linear dose 
response relationships will be considered if residual plots reveal significant deviations of the 
models from linearity. Gender differences in the shape of the curve for NSA will be examined in 
the logistic regression model by including gender main effect and its interactions with dose 
(Hypothesis 1B). Significant interactions between the group factors and dose will be considered 
supportive of systematic group differences in the dose-response relationships between groups. 
If significant interactions are observed, then separate thresholds and curves will be estimated 
within each subject group.  
Specific Aim #2: To assess the threshold and dose-effect curve for the positive and 
negative/aversive subjective effects of IV nicotine at low doses and its relationship to nicotine 
reinforcement. Hypothesis #2 A: The threshold for the positive effects will be between 0.0125 to 
0.1 mg/70 kg, for the negative/aversive effect it will be ≥ 0.1 mg/70 kg. Hypothesis #2B: Nicotine 
reinforcement will be positively correlated with the positive and negatively correlated with the 
negative/aversive subjective effects of IV nicotine.   
Aim 2 Analysis: The subjective-positive effects of nicotine which will be determined by the 
main dependent variables of scores on the “like the drug” and “want more drug” items of the 
Drug Effects Questionnaire, ranging from 0 to 100. The negative aversive effects of nicotine will 
be determined by the “dislike the drug” and “lightheaded/dizzy” item of the DEQ. The analysis 
for Specific Aim #2A will be similar to the analysis described for Specific Aim #1A except that 
the dependent variables will be continuous and thus we will use random effects linear 
regression. Gender effects will be explored also as outlined for Specific Aim #1B. Prior to 
analysis, we will also assess the distribution of the DEQ items and apply transformations as 
necessary. Furthermore, the mean ratings at each dose will be compared to 0. To assess the 

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relationship between nicotine reinforcement and positive subjective effects, and between 
nicotine reinforcement and negative subjective effects (Specific Aim #2B), we will use mixed 
effects models with the proportion of NSAs per session as the dependent variable, positive 
(negative) subjective effects in response to the sample dose as the main predictor of interest (in 
separate models for positive and negative effects). Nicotine dose, gender and the interactions 
among subjective effects, dose and gender will also be assessed. Non-significant interactions 
will be dropped from the models via backward elimination subject to the constraint that the 
models will be hierarchically well-formulated at each step. Statistically significant associations 
between subjective effects and NSA across doses and gender are expected but we will also 
explore whether these relationships vary by gender and dose.  
Exploratory Aim #1: To examine the association between baseline 3HC/cotinine ratio and 
nicotine reinforcement threshold. To test this hypothesis, correlation analysis including 3 
HC/cotinine ratio and nicotine reinforcement threshold will be performed in the total sample as 
well as in subgroups (male vs. female smokers). 
 
 
Rationale for sample size: Power for Specific Aims 1 and 2 is based on our preliminary 
studies comparing nicotine doses of 0.1, 0.2, 0.3 and 0.4mg to saline (34). We consider a 
difference between 50% (half of infusions in favor of nicotine) and 67% (two-thirds in favor of 
nicotine) as clinically meaningful. With our sample of 72 subjects we can detect such a 
proportion (67%) as statistically different from 50% with 80% power assuming two-sided test 
and alpha=0.05 (Specific Aim 1). Also with our sample of 72 subjects, we can detect medium 
effects (d’=0.34) for the threshold tests on “good effects” and “drug liking” under the same 
assumptions (Specific Aim 2).  
13. Risks and benefits: 
Potential risks 
There are potential risks, discomforts and inconveniences associated with the participation in 
this study. These may be due to nicotine administration, blood drawing, and other study 
procedures. 
1) The administration of nicotine may cause cardiovascular, autonomic, and gastrointestinal 
complications. Large doses of nicotine may cause nausea, vomiting, abdominal pain, hyper 
salivation, diarrhea, dizziness, confusion, hearing and vision problems, syncope, seizures, 
hypotension, irregular pulse, and death. However, these toxic effects occur at doses 10-20 
times that which will be used in our study.  Other potential risks from this study include 
administering a drug that has addictive potential. However, since only subjects with an 
extensive history of cigarette use are to be included, we will not be exposing subjects to the 
risks of nicotine for the first time. Additionally, we are not enrolling subjects who are seeking 
treatment to quit smoking. Over the last 5 years, we have administered nicotine intravenously to 
more than 100 smokers and have not encountered any adverse events from nicotine. 
2) Blood Drawing: Subjects will have approximately 200 ml of blood drawn as a result of their 
participation in the study. Blood drawing can cause some pain and may result in bruising.  
3) Study procedures: On the test days, subjects will not be able to smoke for 10 hours. During 
this cigarette abstinence period, subjects may experience symptoms of nicotine withdrawal such as 
craving cigarettes, mild anxiety, restlessness, irritability, difficulty concentrating, loss of energy, and 
excessive hunger.    
Protection of Subjects 
In order to participate in a study, each subject must give informed consent. All potential risks will 
be described in detail to the subjects in the consent form. The personnel in the laboratory have 

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been certified in either Advance Cardiac Life Support (ACLS) or Basic Life Support. If a problem 
arises, the subject will be treated immediately.        
Confidentiality in this study is of the utmost importance to us. All information obtained will be 
stored in coded form. The names of the subjects will be used in hospital records.   
14. Safety 
Prior to initiating any research activity, each subject must give informed consent. Before the 
study, the subjects will be informed about all potential risks of the study. Our inclusion and 
exclusion criteria will be applied by experienced professionals who will be carefully trained and 
monitored in order to accept only appropriate subjects into the study. Thus, effective screening 
will exclude subjects who would be placed at a greater risk. Eligibility is determined by the 
medical and psychiatric history, drug use history, the physical examination, and the laboratory 
studies done prior to beginning this research protocol. 
 
 
For nicotine administration sessions, a physician will be present and subjects will be attached to 
a cardiac monitor as well as a blood pressure and heart rate monitoring device. An IV catheter 
will be in place throughout the session. Subjects will be administered nicotine only if the systolic 
blood pressure is <150 mmHg and heart rate is <100 beats/minute. Subjects will be terminated 
from the study if the blood pressure at any time is >170/110 mm Hg, the heart rate is >120 
beats/min, or if they develop signs and symptoms compatible with nicotine toxicity. Subjects will 
remain in the laboratory for at least an hour after the last nicotine administration. These 
procedures have been developed as part of our IND for IV nicotine.  
Confidentiality will be protected by having records identified by code number only with the 
master list including names kept in a sealed envelope in a locked file in the Principal 
Investigator's office and by the pharmacy. Subjects will be given telephone numbers to call in 
case of emergency, 24 hours a day.    
14.1 Potential benefits of the proposed research to the subjects and others.  There will be 
no direct benefit to subjects participating in this study. However, subjects will receive complete 
medical and psychological evaluation. Cigarette smokers will be given anti-smoking literature 
and treatment resources will be provided for smoking cessation.  
14.2 Importance of the knowledge to be gained. This proposed study may help to develop 
new and more effective tobacco control policies. We believe that the risk/benefit ratio for this 
study is acceptable, and that the benefits of the proposed studies outweigh the potential risks to 
subjects.  
14.3 Data safety and monitoring plan: The Principal Investigator will conduct a review of all 
adverse events and determine the attribution and grade of severity of the adverse event by 
using the following scales: 
Attribution of Risk Categories: 
Definite:  Adverse event(s) will clearly be related to investigational agent(s) or other 
intervention 
Probable: Adverse event(s) will likely be related to investigational agent(s) 
Possible:   Adverse event(s) may be related to investigational agent(s) 
Unlikely:  Adverse event(s) will doubtfully be related to investigational agent(s) 
Unrelated: Adverse event(s) will clearly not be related to the investigational agents(s) 
Grades of Risk: 

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0: No adverse event or within normal limits 
1:  Mild adverse event 
2:  Moderate adverse event 
3:  Severe adverse event resulting in hospitalization or prolongation of existing 
hospitalization, a persistent or significant disability/incapacity, or a congenital 
anomaly/birth defect  
4:  Life-threatening or disabling adverse event 
5:  Fatal adverse event 
 
 
 
Serious adverse events (SAEs) include any untoward medical occurrence that at any dose 
results in death or the immediate risk of death, hospitalization or the prolonging of an existing 
hospitalization, persistent or significant disability/incapacity or a congenital anomaly/birth defect. 
Subjects will be terminated from participation if the investigator feels that subjects' health or 
well-being may be threatened by continuation in the study. Serious unanticipated and 
anticipated adverse events will be reported within 48 hours to the VA Hospital and Yale IRB, 
and NIDA. We will directly report to the FDA, whenever their magnitude or frequency exceeds 
expectations.   
 
The risk associated with participating in this study is moderate, because nicotine administered 
may be associated with mild side effects. Serious side effects associated with this treatment are 
not expected. This project will be monitored by a Data and Safety Monitoring Board (DSMB) 
because the study involves double-blind treatment of smokers with nicotine. This board is 
composed of persons not otherwise affiliated with the clinical study who are experienced in 
various aspects of the conduct of clinical trials for the treatment of addictive disorders. We 
propose three investigators located here in Connecticut who are not directly involved in this 
study – Declan Berry, Ph.D., Sherry McKee, Ph.D., and David Fiellin, M.D. as the members of 
the DSMB. The members of the DSMB and all study Investigators will complete Conflict of 
Interest forms created by Yale’s IRB in accordance with NIH guidelines.   
In order for the DSMB to fulfill its mission of assuring the safety of human subjects and the 
scientific integrity of the studies conducted, the Board will have access to accumulating study 
outcome data in a manner that will protect its confidentiality and preserve its statistical integrity. 
The Board will examine accumulating data to assure that the risks and benefits of participation 
remain acceptable and that the results of the study will be considered scientifically reliable. The 
conditions under which the Board will examine this data are described below. This monitoring 
will be consistent with NIH policy regarding the protection of human subjects in research, and 
FDA guidance on statistical practices for clinical trials (ICH E9) and good clinical practices (ICH 
E6). In general, the data to be reviewed will include screening data, baseline data, efficacy data, 
and safety data.   
The study will be monitored for safety in an ongoing way as well as three times each year 
formally by the DSMB.  The P.I. will attend an initial part of this meeting to present the study’s 
adverse events and ongoing subject accrual, as well as any potential study design changes 
under consideration.  The remainder of the meeting will not include any direct study personnel 
until the end of the meeting, when the DSMB will convey directly to the P.I. any safety or study 
conduct concerns, as well as requests for potential interim analyses.    

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Following each DSMB meeting written minutes will be prepared and distributed summarizing 
any recommendations. These written reports will insure timely communication with the study P.I. 
with preparation of any protocol amendments necessary. After each DSMB meeting, this written 
report will describe all recommendations including additional safety steps. The FDA adverse 
drug experience reporting timelines will be utilized as timelines to disseminate feedback from 
the DSMB to the principal investigator and sub investigators. That is, three days for acute 
circumstances and ten days for non-acute circumstances.  
 
 
 
 
 
15. Informed consent: Subjects will be recruited from the New Haven area by newspaper 
advertisements and fliers. Interested subjects will be informed about the study over the 
telephone and asked for current use of drugs and medical problems. If subjects are interested, 
they will then come into the clinic for a full screening evaluation. Upon arrival, a research 
assistant will read the detailed consent form and will ask questions to make sure that the 
subjects understand the procedure and their rights and informed consent will be obtained.   
16. Information Security/Confidentiality: Confidentiality in this study is of the utmost 
importance to us. All information obtained will be stored in coded form.  
 
Personally identifiable information (PII) and protected health information (PHI) that is obtained 
from subjects or about them will be protected by the research team who will follow all guidance 
provided in the following VHA HANDBOOKS and DIRECTIVE: 
 
• 
VHA HANDBOOK 1605.1, PRIVACY AND RELEASE OF INFORMATION Dated May 
17, 2006 
 
• 
VHA HANDBOOK 1907.01, HEALTH INFORMATION MANAGEMENT AND HEALTH 
RECORDS Dated August 25, 2006 
 
• 
VHA HANDBOOK 6500, INFORMATION SECURITY PROGRAM Dated September 18, 
2007 
 
• 
MEMORANDUM FOR UNDER SECRETARIES, ASSISTANT SECRECTARIES AND 
OTHER KEY OFFICIALS, SUBJECT: Protecting Information Security and Privacy Dated 
February 27, 2009 
 
• 
VHA HANDBOOK 1200.12, USE OF DATA AND DATA REPOSITORIES IN VHA 
RESEARCH Dated March 9, 2009 
 
All data collected will be the property of the Department of Veterans Affairs whether in paper or 
electronic form and will be secured utilizing the following methods: 

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Paper:  
• 
All paper documents will be stored on VA property unless authorized by the Director, 
Information Security Officer, and Privacy Officer in writing.  
• 
All paper documents will be locked in an approved file cabinet with only members of the 
research team having access.  
 
 
 
 
 
Electronic: 
• 
All information in electronic form will be stored on VA servers behind the VA firewall. 
• 
All portable media will meet or exceed FIPS 140-2 compliance and encryption. And will 
be approved in writing by the Information Security Officer.  
 
The location(s) where information will be stored is (are) Building 35, rooms 19 and 39 
The people or agencies that will have access to the information are the study investigators. 
 
No information related to this research will be released to any third party or disclosed outside of 
the VHA – except as required or permitted by law. 
 
Research records will have identifiers removed and will be stored with a code number linked to 
subjects.  The code will not be derived from any personal identifiers.  The key to the code will be 
kept in a locked file cabinet, located in Bldg 35, room 19. Subjects’ identity will not be revealed 
in any reports or publications resulting from this study. 
 
17. Location of Study: This study will be conducted in Ward G9W (the Biostudies Unit) located 
in Building 1 at the West Haven VA Medical Center.   
 
18. Payment: Subjects will be paid $30 for participating in the screening and $130 for each of 
the 5 lab sessions and $20 for transportation for each of the 5 test sessions. If the subjects 
choose to terminate a session prematurely, or a session is terminated early for medical reasons, 
they will receive full payment for that day.  If they become ineligible to continue in the study due 
to non-compliance with study procedures, they will only be paid for the portions of the study in 
which they have participated. Subjects may also earn $20 for referring people they know who 
also smoke cigarettes and are eligible for study participation. A contingency payment of $20 will 
also be given for transportation for a visit that wasn’t fulfilled in the outlined time frame within 
the protocol.  Subjects may be paid up to $780 if all parts of the study are completed.  
 
19. Funding Source: An RO1 grant from NIDA (pending). 

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20. Duration: The new study design will take approximately 3 years to complete.    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
21. References: 
 
Battig K, Buzzi R, Nil R (1982) Smoke yield of cigarettes and puffing behavior in men and 
women. Psychopharmacology 76: 139-48 
Bell SL, Taylor RC, Singleton EG, Henningfield JE, Heishman SJ (1999) Smoking after nicotine 
deprivation enhances cognitive performance and decreases tobacco craving in drug 
abusers. Nicotine Tob Res 1: 45-52 
Benowitz NL (2008) Clinical pharmacology of nicotine: implications for understanding, 
preventing, and treating tobacco addiction. Clin Pharmacol Ther 83: 531-41 
Benowitz NL, Gourlay SG (1997) Cardiovascular toxicity of nicotine: implications for nicotine 
replacement therapy. J Am Coll Cardiol 29: 1422-31 
Benowitz NL, Henningfield JE (1994) Establishing a nicotine threshold for addiction. The 
implications for tobacco regulation. N Engl J Med 331: 123-5 
Benowitz NL, Jacob P, 3rd (1984) Daily intake of nicotine during cigarette smoking. Clin 
Pharmacol Ther 35: 499-504 
Benowitz NL, Jacob Pd (1990) Intravenous nicotine replacement suppresses nicotine intake 
from cigarette smoking. Journal of Pharmacology & Experimental Therapeutics 254: 
1000-5 
Benowitz NL, Jacob PI, Ahijevich K, Jarvis MJ, Hall S, LeHouzec J, Lichenstein E, Henningfield 
JE, Tsoh J, Hurt RD, Velicer W (2002) Biochemical verification of tobacco use and 
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