The Potential of Kava in Enabling Tobacco Cessation - Its Holistic Effects in Managing Stress and Insomnia Associated With Abstinence
Phase: PHASE2
Conditions: Smoking
Sponsor: University of Florida

 
Protocol Title: The potential of kava in enabling tobacco cessation - its holistic effects in 
managing stress and insomnia associated with abstinence 
 
 
Investigator(s): 
 
• Principal Investigator: Ramzi Salloum, Ph.D. 
• Protocol Statistician: Zhiguang Huo, Ph.D. 
• Listing of any Co-Investigator(s): 
 
Chengguo Xing, PhD 
 
John Malaty, M.D. 
 
Frank A. Orlando, M.D. 
 
Roberto Firpi-Morrel, M.D. 
 
Carla Fisher, PhD 
 
Demetra Demetriou Christou, PhD 
 
IRB of Record: UF IRB-01 
 
IRB #: 202300887 
 
Study Site: UF Health Community Health and Family Medicine 
 
Study Sponsor: National Institute of Health: National Center for Complementary and Integrative Health   
 
Protocol/Sponsor Number: R33AT012328 
 
Date of Original Protocol: 06/08/2023 
 
Date of Current Protocol: 09/10/2024 
 
Version of Current Protocol: 0003.0 
 
 

Table of Contents 
Abstract ............................................................................................................................................................................. 3 
1. 
Scientific Rationale and Background: ................................................................................................................... 3 
2. 
Study Aims and Objectives: .................................................................................................................................... 4 
3. 
Study Schema and/or Schedule of events: .......................................................................................................... 5 
4. 
Study Design ............................................................................................................................................................. 8 
5. 
Selection of Subjects ............................................................................................................................................... 8 
6. 
Study Procedures ................................................................................................................................................... 10 
7. 
Possible Discomforts and Risks ........................................................................................................................... 11 
8. 
Possible Benefits .................................................................................................................................................... 12 
9. 
Adverse Events/Unanticipated Problems ........................................................................................................... 12 
10. Statistical Analysis Plan ........................................................................................................................................ 13 
11. Study Monitoring..................................................................................................................................................... 15 
12. Data Integrity and Oversight ................................................................................................................................. 15 
13. Data Management .................................................................................................................................................. 16 
14. Conflict of Interest .................................................................................................................................................. 17 
15. Appendices .............................................................................................................................................................. 17 
16. References .............................................................................................................................................................. 18 
17. Appendix A: ............................................................................................................................................................. 21 
18. Appendix B: Schedule of Events ......................................................................................................................... 33 
19. Appendix C: Summary of Changes ..................................................................................................................... 35 
 
 
 

ABSTRACT 
As the leading cause of numerous preventable diseases, smoking results in half a million premature deaths 
each year in the US and another 16 million American adults living with a serious illness. Indeed, about half of 
smokers will die of smoking-related problems if they do not quit. Most smokers are aware of such deleterious 
health effects and have the intention to quit. Tobacco cessation, however, is very challenging, partly due to 
abstinence-associated stress and insomnia. Current tobacco cessation medications are not designed to 
address these problems, which have contributed to their limited success in enabling tobacco cessation. There 
are currently about 34 million American adult smokers and the number is not expected to decrease significantly 
in the near future. Novel interventions are thus urgently needed that would resolve these challenges, which 
may significantly improve the success rate of tobacco cessation. On the basis of its traditional history and our 
preliminary data, kava is such a candidate. Kava is a traditional beverage consumed among the South Pacific 
Islanders for relaxation, stress reduction, and sleep improvement. It is also marketed as a dietary supplement 
in the US. Incorporating rigorous safety measures, we completed a pilot trial among active smokers with a 
one-week ingestion of a kava supplement. The results for the first time revealed kava’s potential in enabling 
tobacco cessation with promising effects on a panel of biological signatures associated with tobacco use, 
stress, and sleep. The main goal of this R33 application is to replicate the effects of kava on the biological 
signatures of tobacco use, stress, and sleep in addition to its compliance and safety among smokers. We 
propose to perform a double-blind randomized placebo controlled two-arm trial among 76 smokers with 
intention to quit, who will consume AB-free kava at a dietary supplement dose or placebo, 3 times per day for 
4 weeks with two follow-ups. Aim 1 will evaluate the compliance and safety of AB-free kava use among 
smokers and assess changes in smoking behaviors. Aim 2 will quantify a panel of non-invasive translatable 
biomarkers to objectively evaluate AB-free kava’s holistic effects on biological signatures associated with 
tobacco use, stress, and sleep. We hypothesize that AB-free kava is a novel and promising intervention to 
facilitate tobacco cessation via its holistic effects in managing stress and insomnia associated with abstinence. 
If the results from this study support our hypothesis, kava could emerge as an affordable and accessible 
dietary supplement candidate for tobacco cessation. 
 
1. SCIENTIFIC RATIONALE AND BACKGROUND: 
Fig. 1. Impact of one-week kava on urinary TNE (A), plasma PRKACA (B), plasma cortisol (C), and urinary TCE (D). 
Two-tailed paired t-test was performed (n = 21). A ratio of geometric means and 95% CI presented. 
Currently, there are 34 million adult smokers in the US [1, 2] with little indication that this number will decrease 
significantly in the near future [3]. Tobacco use is the leading cause of numerous preventable diseases and 
about half smokers will die of smoking-related problems if they do not quit [1]. Given that ~ 70% of adult 
smokers want to stop smoking and over 50% of them make a quit attempt annually [4], this devastating health 
burden could be significantly reduced if the success rate of tobacco cessation can be improved. It was also 
observed that two thirds of those planning to quit were interested in trying complementary approaches to 
facilitating tobacco cessation [1], which is currently lacking. Effective complementary tobacco cessation 
interventions, therefore, need to be developed to support smokers achieve cessation and reduce the risk of 
associated diseases. 
The first-line medications to facilitate tobacco cessation include nicotine replacement therapy, bupropion, and 
varenicline. These medications typically result in moderate success rates but suffer from significant relapses 
[5]. Some of them are also associated with various adverse side effects, which may contribute to their limited 
P re -k a v a
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success in tobacco cessation. One common side effect is trouble in sleeping [6]. It has been even proposed 
that adjunctive treatment targeting sleep disturbance may improve abstinence rates [6, 7]. 
Kava has a long history of safe use as a beverage to help people relax and improve sleep with daily dosages 
ranging between 750 – 8,000 mg kavalactones [8-12]. WHO and others have reviewed the reported kava 
safety data and concluded that kava’s purported hepatotoxic risk is rare if any (< 0.3 case per one million daily 
doses) [13-21], particularly with the right cultivars and preparations [14]. Kava therefore has always been on 
the US market as a dietary supplement. Since traditional kava has been safely used for centuries and its daily 
kavalactone dose is significantly (3 – 100 times) higher than its anxiolytic and dietary supplement regimens 
(120 – 280 mg kavalactones daily) [8-12, 22], kava’s hepatotoxic risk may be associated with ingredients 
enriched in the anxiolytic preparations. One possibility is the higher abundance of flavokavains A and B in the 
anxiolytic form (~100 times) than in traditional kava [23]. Flavokavains A and B are also much more abundant 
in low-quality kava cultivars than in noble kava cultivars [24]. They are the most cytotoxic compounds in kava 
[23, 25] and have induced hepatotoxicity in lab animals [26, 27]. These data suggest that flavokavains A and 
B likely account for kava’s hepatotoxic risk. 
A kava formula, free of flavokavain A and B and mimicking traditional kava preparation, has been 
developed by Thorne (namely AB-free kava). AB-free kava has rigorous Chemistry Manufacturing and 
Controls (CMC) documentation, high quality control and quality assurance, and an enabled IND status 
(142838) with an ongoing double-blind randomized placebo-controlled trial among patients with generalized 
anxiety disorder (NCT03843502) using the same regimen as proposed in this application. This formula has 
also demonstrated outstanding safety profiles in several animal models [28-31]. The pharmacokinetics of six 
major kavalactones in AB-free kava has been characterized among healthy participants [32], indicating that 
three times daily regimen offers better kavalactone exposure. 
Based on its relaxing and sleep improvement activity [33-36], kava has the potential to facilitate tobacco 
cessation and could be potentially more effective. Its dietary supplement status may make it more acceptable 
to smokers as well [37]. These potential benefits were further supported by the results of our pilot kava trial 
among smokers ([38]) that one week of kava use reduced biomarkers on tobacco use, stress and increased 
biomarkers on sleep. 
The main goal is to replicate the effects of kava on biological signatures of tobacco use, stress, and sleep in 
addition to its compliance and safety among smokers. 
 
2. STUDY AIMS AND OBJECTIVES: 
 
 
This study has two aims. Aim 1. To document AB-free kava compliance, identify potential issues and characterize 
its effects on smoking, stress, and sleep associated behaviors. Aim 2. To quantify a panel of non-invasive clinically 
translatable biomarkers to objectively evaluate AB-free kava’s holistic effects on biological signatures associated 
with tobacco use, stress, and sleep. 
 
HYPOTHESIS: We hypothesize that AB-free kava (a properly formulated kava) is a novel promising intervention to 
facilitate tobacco cessation via its holistic effects in managing stress and insomnia associated with abstinence. To 
test this hypothesis, we will perform a double-blind randomized placebo controlled two-arm trial among 76 smokers 
with intention to quit, who will consume AB-free kava at a dietary supplement dose or placebo, 3 times per day for 4 
weeks with two follow-ups.  
 
A. Primary Objective: To evaluate AB-free kava compliance and identify potential issues. 
B. Secondary Objective(s): To examine whether AB-free kava has the potential to help facilitate tobacco 
cessation – tobacco cessation-related questionnaires and reduction in urinary TNE (total nicotine equivalents, 
which measures nicotine, cotinine, and 3-hydroxycotinine and their conjugates separately). To examine 
whether AB-free kava has the potential to reduce stress and improve sleep – standard questionnaires and 
associated biomarkers (plasma PRKACA, plasma cortisol, urinary TCE, and urinary NAS). 
C. Exploratory Objective: To examine the sociocultural context to better understand factors that may play a 
role in participants’ enrollment and willingness to engage in kava use as a dietary supplement in tobacco 

cessation. To use a wrist wearable device to objectively monitor parameters related to sleep, which 
complement self-reported sleep measures. 
 
3. STUDY SCHEMA AND/OR SCHEDULE OF EVENTS: 
 
STUDY SCHEMA 
 
 
This is a double-blind randomized placebo-controlled intervention trial. Methods of the protocols have been 
established in the PI and Co-I’s laboratories to adequately answer the questions addressed in the objectives. The 
trial will require resources from the UF Family Medicine Clinics and UF Consent2Share to help enroll active 
smokers with the intention to quit, who are otherwise healthy, to be randomized into the placebo and AB-free kava 
(225 mg dose) arms, being exposed for four weeks, with a total of six visits (Week 0, 1, 2, 4, 8 and 12) to evaluate 
the compliance and potential issues of AB-free kava use among the participant, explore the potential effect of the 
AB-free kava intervention on tobacco dependence, tobacco use, stress and sleep and associated biomarkers. 
Placebo or AB-free kava interventions are 4 weeks long with one capsule each time and three times daily 
approximately administered via oral at 8 AM, 1PM, and 6PM (total of 3 capsules daily). The dose of AB-free kava 
for 225 mg regimen will be 75 mg of kavalactones per capsule. There will be no dose modification and the use 
will discontinue if severe adverse effect is detected, which is detailed later. 
Clinic Staff members from the UF Health Family Medicine Main Street Clinic and Spring Hill Clinic, under the 
supervision of Dr. Malaty and Dr. Orlando, will identify potential participants and briefly introduce the overall 
goal of the study, typically during the clinic visit. Once a potential participant is identified, the clinic staff member 
will refer the candidate to the study coordinator. The study coordinator will conduct a pre-screening interview 
to explain the study, its potential benefits/risks, and determine the eligibility. Those meeting primary 
inclusion/exclusion criteria and interested in participation will be scheduled for an in-person assessment. At the 
assessment visit, participants will be informed and will verbalize understanding that consent is voluntary and 
that they have the right to withdraw from the study at any time they wish without any consequences to any 
health care they are receiving currently or in the future. After having their questions answered, if they would like 
to participate in the study, they will agree to refrain from engaging in any other smoking cessation while 

participating in this study and sign an informed consent form. Participants are informed that they will receive a 
$50 gift card at each Visit 1 – 6 that will total to $300 if they attend all visits. This $300 amount does not include 
the optional $25 that select subjects may receive for consenting to do the Post-Treatment interview at Visit 4 
(or whenever they stop treatment). The post-treatment interview is not required and will not create a deviation 
if missed. If subject’s attend all visits and do the optional Post-Treatment interview, then they can receive a 
total of $325.  
 
Once a participant signs the consent form electronically in REDCap, s/he will perform a breath CO test to 
evaluate smoking status. Blood will be screened for ALT, AST, ALP, and total bilirubin. Pregnancy test for 
females of childbearing potential will be done with a spot urine. Upon confirming tobacco use, normal liver 
function, and other criteria, qualified participants will be enrolled into this study, set up Visit 1 (typically within 
one week), and randomized into one of the two study arms. A GT3X+ accelerometer  wearable device will be 
provided to the participant and will be worn for four days before the first four visits at Week 0, 1, 2, and 4. The 
wearable device will use a micro-electro-mechanical system (MEMS) based accelerometer and an ambient 
light sensor to measure physical activity and sleep. The Research coordinator will provide instruction of the use 
of the wearable device and provide demonstration.  
 
Visits 1 – 6: During each of the following visits (each should take about 30-60 minutes), participants will be 
screened for ALT, AST, ALP, total bilirubin, breath CO test, and questionnaires administered. An additional 
blood sample (10 mL, onsite) and 24-h urine (Participants will be provided the collection container during each 
visit and will bring their urine samples to their next visit) will be used for biomarker assays. The participant then 
will be provided with medications and written instruction of use, supplies for the next 24-h urine collection, and 
scheduled for the next visit. During Visit 1 – 4, the data in the GT3X+ wearable device will be collected by study 
coordinator at each visit. At Visit 4, the GT3X+ wearable device will be collected from the participant. 
 
The questionnaires include: 
• 
Self-Reported Measure of Smoking: documenting the number of cigarettes smoked in the past 7 days. 
• 
Fagerström Test for Nicotine Dependence (FTND): a 6-item scale measuring the level of nicotine 
dependency or addiction. It assesses how soon tobacco use begins each day, which cigarettes during the 
day a person could do without, how smokers cope in places where they cannot smoke, and how frequently 
and how deeply they smoke. 
• 
Modified Cigarette Evaluation Questionnaire (mCEQ): a 12-item scale, rating several dimensions 
(satisfaction, psychological reward, nausea or dizziness, craving relief; enjoyment of airway sensations). It 
assesses the degree to which participants experience the reinforcing effect of smoking. 
• 
Brief Questionnaire on Smoking Urges (QSU-Brief): a 10-item scale, assessing the features of craving, 
including the anticipation of relief of nicotine withdrawal, anticipation of positive outcomes of smoking, desire 
to smoke, and intention to smoke. 
• 
Perceived Stress Scale (PSS): a 10-item scale measuring the perception of stress. It is a measure of the 
degree to which situations in one’s life are appraised as stressful. The scale also includes a number of 
direct queries about current levels of experienced stress. 
• 
Insomnia Severity Scale: a 7-item self-report questionnaire assessing the nature, severity, and impact of 
insomnia. Dimensions evaluated are: severity of sleep onset, sleep maintenance, and early morning 
awakening problems, sleep dissatisfaction, interference of sleep difficulties with daytime functioning, 
noticeability of sleep problems by others, and distress caused by the sleep difficulties. Because of kava’s 
potential benefit to sleep, this questionnaire will generate preliminary data about kava’s mechanism in 
facilitating tobacco cessation. 
• 
Modified Pittsburgh Sleep Quality Index (MPSQI): contains 19 self-rated questions and 5 questions rated 
by the bed partner or roommate (if one is available), which has been widely used to evaluate tobacco-
induced sleep disturbances. 
• 
Modified Ask Suicide-Screening Questions (MASQ): consists of four yes/no questions to identify individuals 
that require further mental health/suicide safety assessment. According to FDA recommendation for any 
interventions with neurological activities, the original ASQ is used to assess suicide risk because of its peer-
reviewed effectiveness and the lower burden on the participants. This study has modified the questions to 
be less intrusive into participants mental health history beyond what’s needed for eligibility confirmation. 

• 
NIH Sleep Diary: consists of 12 self-reported criteria to record the quality and quantity of sleep; use of 
medicines, alcohol, and caffeinated drinks; and how sleepy subject feels during the day. This questionnaire 
is optional and failure to complete it will not result in a deviation.   
  
At the end of the study (Week 12) or when a participant drops out of the study, an exit interview will be performed 
with open-ended questions to obtain feedback about the trial from the participants.  
 
At the end of study treatment, Week 4, or at the time the participant withdraws from this study, subjects will be 
offered an opportunity to participate in a post-treatment interview, which is not required. The post-treatment 
interview will no longer be collected after 25 participants have completed it. If they choose to participate they 
will receive an additional $25 to the $50 they are already being given for their attendance. Participants will be 
purposively sought to ensure comparable subgroups of racial and ethnic minorities and white participants. By 
recruiting subgroups, we can explore cultural similarities and differences in their experiences. We expect to 
recruit 25 participants to ensure thematic saturation. However, data collection and analysis will be concurrent 
to ensure saturation is reached. This interview will help to identify facilitators and barriers to trial enrollment and 
retention. 
 
In-depth, semi-structured interviews will be conducted via phone or Zoom by the research coordinator, given 
their established rapport and trust [39]. Fisher (co-I), a qualitative methodology expert in health behavior 
intervention development, will provide oversight on data collection and analysis. She will also develop the semi-
structured script and train the coordinator on in-depth interviewing. Interview questions will explore participants’ 
experiences with kava to identify critical factors to promoting future trial enrollment, adherence, and sustained 
healthy behavior change [40, 41]. Questions will explore facilitators and barriers to enrollment and retention as 
well as sociocultural factors informing participants’ health behavior and ongoing willingness to engage in kava 
use. These include exploring the influential role of cultural norms or beliefs, experiences within their family 
system, and prior use or beliefs about kava. The interviews need to be audio recorded so that they can be 
professionally transcribed. The transcriptions of interviews are the qualitative data that are then thematically 
analyzed by a qualitative research scientist. Without audio files or transcriptions, there is no reliable data. This 
is standard and best practices in qualitative methodology.  
 
Data will be managed using a data management software program (ATLAS.ti). A thematic analysis will be 
conducted by a qualitative analyst trained by Fisher, who will oversee analysis and codebook development [42, 
43]. To maintain sensitivity to cultural differences, data will be segmented by race and ethnicity and analyzed 
by group to triangulate findings. An additional coder will be used to validate the final codebook to further promote 
rigor in analysis [44]. Audio recordings will begin after consent has been obtained and captured using a digital 
recording device. Audio files (mp3) will be downloaded immediately after the interview onto a secure UF 
computer. Files will be uploaded for professional transcription with a vendor that has been approved by UF risk 
management with associated approved procedures. Files will be saved as a code instead of patient names. 
This code will be used on transcriptions as well. Only the PIs and relevant study personnel (e.g., Co-I 
overseeing the qualitative analysis) will have access to the code-identifier file, which will be stored in on a UF 
computer. All transcriptions (i.e., data) will be de-identified prior to thematic analysis to ensure confidentiality of 
participants.  No identifying information will be used in any publications or presentations to protect the 
confidentiality of participants. Audio files will be destroyed once analysis has been completed. Transcripts will 
be destroyed once all analyses are completed or within two years once the study period has ended. 
 
Data and biological sample collection and storage All data (participant information, questionnaire responses, 
values of biological samples and others) will be stored in a REDCap database. REDCap is a HIPAA-compliant, 
highly-secure, and intuitive-to-use web-based application designed to capture and store data for clinical 
research, including questionnaire data from research participants. Data will be exported into a SAS data set for 
analysis. Data integrity will be evaluated using descriptive statistics (e.g., means, standard deviations, 
frequencies, percent, range) appropriate for measurement levels. Checks for implausible or out-of-range 
values, distributional forms, and missingness will be performed. 
 
For biological samples, a research assistant will retrieve the urine and blood samples from the Clinic within 1 
hour after the participant’s visit and deliver to the Xing lab. The total volume of the urine sample will be recorded 
to the closest 10 mL. The urine samples, upon mixing well, will be split into 10 x 1 mL, 5 x 15 mL, 2 x 100 mL 

and stored at – 80ºC. The blood samples will be processed into plasma, buffy coat and red blood cells and 
stored at – 80ºC. Detailed information of these samples, including participant ID, visit #, sample information, 
and missed dosing or sample(s), will be recorded in the REDCap database. 
 
4. STUDY DESIGN 
To rigorously test our hypothesis and build the solid foundation for future AB-free kava translation among addicted 
smokers to facilitate tobacco cessation, we propose a double-blind randomized placebo-controlled longitudinal trial 
(4-week AB-free kava intervention vs. placebo with two follow-ups). Briefly, addicted smokers with INTENTION to 
quit will be enrolled and randomized into two groups (those NOT willing to quit will be referred to Tobacco Free 
Florida, the state tobacco cessation program, or other tobacco cessation studies). One group will take placebo 
capsules and the other group will take AB-free kava capsules (one capsule each time, 3 times daily, each capsule 
is 75 mg kavalactone) for four weeks. Safety monitoring and sample collections will be implemented at Week 0, 1, 
2, 4, 8 and 12 respectively. Two follow-ups (Week 8 and 12) are designed to 1) explore the sustainable potential 
of AB-free kava; and 2) capture delayed adverse effects if any, both of which are critical for participants and future 
development. AB-free kava regimen proposed herein remains the same as in the pilot trial [38], supported by our 
recent pharmacokinetic results (the half-lives of the main ingredients in AB-free kava are no more than 3 hours). 
The 4-week AB-free kava exposure is expected to provide sufficient data about AB-free kava’s compliance, efficacy 
and safety while minimizing potential risks among the participants. At the end of Week 12, all enrolled participants 
will be recommended to Tobacco Free Florida to maximize the chance of tobacco cessation. 
National Institute of Health (NIH) is considering to fund the proposed clinical trial via a 3-year clinical trial grant 
through the R33 mechanism from National Center for Complementary and Integrative Health (NCCIH). The 
methods, protocols, and expertise are all in place in the PI and Co-I’s research group. The proposed objectives are 
expected to be achievable in the 3-year funding period. The safety of the participants will be closely monitored that 
the intervention will stop following the rules below: 
 
1. Participants will be assessed for ALT, AST, ALP and total bilirubin using blood samples collected during the 
visits at baseline, week 1, 2, 4, 8 and 12 to monitor potential acute or delayed hepatotoxic risk. During the visits 
at baseline, week 1, and 2, the participant will receive the drug supplies for 1 week (at baseline), 1 week (at 
week 1), and 2 weeks (at week 2). The ALT, AST, ALP and total bilirubin test results will be available to the 
research coordinator within 24 hours after the blood sample collection and the participant will be notified of the 
results immediately after they become available if the levels are out of the range as defined below. The patient 
will be instructed to stop taking the study drug if they are not in contact with the clinic regarding their lab results 
within 24 hours of the blood draw. During the period of time between blood sampling and lab results, which is 
within 24 hours, the participant will continue to take the medication as scheduled. This is the standard protocol 
for the clinical evaluation of standard therapeutics, even those with high risk of hepatotoxicity. Given the very 
low risk of hepatotoxicity reported for kava (< 0.3 case per 1,000,000 dosages), the protocol has built in adequate 
measures to minimize the potential risk associated with kava use without significantly compromising the goal of 
the trial. Participants, whose ALT, AST, ALP or total bilirubin increases > 3 x the upper limit of normal (ULN) but 
≤ 5 x ULN, will retest after 48 to 72 hours. The patient will continue taking the study drug during this time. If ALT, 
AST, ALP or total bilirubin increases to >5 x ULN, the study drug will be discontinued and participant referred 
for further clinical evaluation and treatment. For any increase in ALT, AST, ALP or total bilirubin >3 x ULN 
associated with fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever and/or rash, study drug 
will be discontinued and participant referred for further clinical evaluation. 
 
2. When 25% participants complete all study visits (Visit 0-6), safety data of all participants will be analyzed by 
Data Integrity and Safety Committee (DISC) independently to determine whether AB-free kava intervention has 
any potential risk. The same practice will be implemented at 50% and 75% completion. 
 
5. SELECTION OF SUBJECTS 
Justification for UF Health Family Medicine Main Street Clinic and Spring Hill site a) Over 1700 adult smokers 
visited the Main Street Clinic last year for annual checkup, >50% of whom smoke at least 10 cigarette/day. Although 
our exclusion criteria is stringent (detailed below), we expect at least 15 – 20% recruitment rate given the high 
success to recruit participants in family clinics for tobacco trials; b) successful track record of recruiting smokers to 
support clinical research, including collaborations between Drs. Salloum and Malaty (co-Is), who have previously 

recruited 120 adult smokers from the same clinic in 4.5 months (NCT03836573); c) electronic health record 
information of patients in the clinics will help identify eligible participants – those without previous liver diseases; 
and d) most importantly, the clinical expertise, resources, and facilities will minimize potential adverse effects in 
this trial. The Spring Hill site has a similar patient population and clinical research structure. We propose two sites 
to maximize the enrollments. 
There are no additional requirements with respect to gender, employment, geographical, language, or other factors. 
Our targeted accrual goal is 76 active smokers. Based on our previous enrolling experience at the Family Clinic 
and our rather stringent inclusion/exclusion criteria, the enrollment is expected to be 1.5 – 2.5 years with the 
duration of each participant to be around 12 weeks. 
The participants will be referred to study team via a UF Health Family Medicine Main Street Clinic and Spring Hill 
sites. Specifically, clinic staff members from the clinic under the supervision of Dr. John Malaty and Dr. Frank 
Orlando will identify potential participants and briefly explain the study. Once a potential participant is identified, the 
clinic staff will refer the candidate to the study coordinator. Participants will also be referred to the study team 
through the UF Consent2Share program. 
 
Justification for excluding pregnant women. Given the proposed mechanism of AB-free kava to facilitate the 
reduction of tobacco use through the modulation of stress, pregnant women will be excluded from this study 
because pregnancy is expected to introduce significant changes on mental status and hormone physiology. Such 
variations are expected to compromise the sample size justification and therefore the primary goal of this early-
phase clinical study. 
 
Total Number of Subjects (should be total of a + b): 76 
Total Number of Subjects (affiliate sites, if applicable): not applicable 
Total Number of Subjects (UF site): 76 
 
Key Inclusion Criteria:  
A) adults aged 21 years or above (legal age for smoking in the U.S.) and 75: there is no knowledge that 
kava’s pharmacology could be age dependent; the upper age of 75 is defined to minimize the risk for 
elderly;  
B) self-reported smoking at least 10 cigarette/day for the past year with INTENTION to quit;  
C) expired carbon monoxide level of more than 8 ppm at recruitment;  
D) willingness to participate in the proposed study;  
E) access to a functional telephone;  
F) expected presence in the study’s geographical area for the next 4 months;  
G) not currently enrolled in any smoking cessation programs; and  
H) for female subjects of childbearing potential will be required to practice acceptable methods of birth 
control (the acceptable methods of birth control include birth control pills, Birth Control Shot, Birth Control 
Implant, IUD, Diaphragm, and cervical cap). 
I) if a participant takes kava dietary supplement, a 2-week washout period is needed for the participant to 
initiate this study or if a participant participated in a kava trial before, such as the kava JEK trial, the 
participant could be enrolled if the inclusion criteria above are met, including the 2-week washout period. 
Key Exclusion Criteria (any of the following):  
A) diagnosed with cancer (other than non-melanoma skin cancer);  
B) diagnosed with liver dysfunction or with previous liver diseases;  
C) levels of ALT, AST, ALP or total bilirubin over limit of normal (ULN) range at prescreen;  
D) inability to refrain from acetaminophen, alcohol (no more than one drink daily via self-report), or other 
potentially hepatotoxic substances;  
E) use any other non-cigarette nicotine containing products such as smokeless tobacco, cigar or e-
cigarettes; or  
F) are pregnant or nursing (lactating) or of childbearing age planning to become pregnant or unwilling to 
use adequate contraception during the study; 
G) participant answered “Yes” to any of the MASQ questions 1 through 4, or refuses to answer. If subject 
answers ‘Yes’ to question 4 but the most recent suicide attempt took place >12 months from screening visit 
then subject is still eligible.  

 
 
6. STUDY PROCEDURES 
 
Enrollment and study procedures Permission to conduct this study will be obtained from the UF IRB prior to 
start. Clinic Staff members from the UF Family Clinic will identify potential participants and briefly explain the study. 
Once a potential participant is identified, Clinic Staff members will refer the candidate to the study coordinator.  The 
study coordinator will conduct a pre-screening interview to determine the eligibility. Those meeting primary 
inclusion/exclusion criteria and interested in participation will be scheduled for an in-person assessment. At the 
assessment visit, participants will be informed and will verbalize understanding that consent is voluntary and that 
they have the right to withdraw from the study at any time they wish without any consequences to any health care 
they are receiving currently or in the future. After having their questions answered, if they would like to participate 
in the study, they will agree to refrain from engaging in any other smoking cessation while participating in this study 
and sign an informed consent form. 
Once a participant signs the consent form electronically in REDCap, the participant will complete breath CO test to 
evaluate smoking status. Screening procedures performed per Standard of Care within the screening window can 
be used even if prior to consent. Upon confirming tobacco use, normal liver function, no alcohol abuse (via self-
report and questionnaires), qualified participants will set up Visit 1 (typically within one week), and be randomized 
into one of the two study arms. During each of the following visits, participant liver function will continue to be 
monitored with blood tests, a breath CO test, and questionnaires. An additional blood sample (10 mL) and 24-h 
urine (collected the day before the visit, patients will be provided collection container during each visit) will be used 
for biomarker assays. The participant then will be provided with medications, written instruction of use, and supplies 
for the next 24-h urine collection, and scheduled for the next visit. The questionnaires to be administered have 
been previously listed in the Study Schema and/or Schedule of events section. 
 
Randomization Participants who meet eligibility criteria will be randomized to the AB-free kava (225) or the placebo 
group using a 1:1 allocation scheme, stratified by age, gender and heavy/light consumption of cigarettes per day. 
IDS randomizes the subject based on the criteria entered with the first Order placed in EPIC for Study IP. IDS does 
not provide any documentation to the study team that randomization occurred. Upon completion of all proposed 
analyses, IDS will provide the randomization record to the PI, Co-Is and Dr. Huo to un-blind assignment. As IDS 
will operate independently of the study team, the study will be a double-blind trial. 
 
Intervention AB-free kava (225) and placebo will be obtained from Thorne Research Inc. Chemistry, Manufacturing 
and Controls (CMC) data have been reviewed by Food and Drug Administration (FDA) with an enabled 
Investigational New Drug (IND, #142838) for a trial among patients with generalized anxiety disorder (GAD). The 
IND for a similar study among smokers with NO intention to quit has been approved (IND #157256) and this study 
will be added as an amendment. Such AB-free kava capsules have been analyzed in-house as well for its 
abundance of kavalactones and lack of flavokavains A and B by our established LC-MS/MS method [45]. AB-free 
kava or placebo will be administered as follows: one capsule by mouth ideally with meals three times a day (around 
8:00 a.m., 1:00 p.m., and 6:00 p.m.) for 28 days. This will result in a daily dose of 225 mg kavalactones for AB-free 
kava group participants. If a dose is missed, participant will not double the dose at the next scheduled time but 
document the missed dose and return the missed dose at the next visit. 
Retention strategies and incentives The study team has an excellent history of retaining clinical trial participants. 
We will always use respectful, empathetic communication and be considerate of participants’ time when scheduling 
research activities. Compliance and retention will be maximized via the following methods: a) close monitoring 
during participation; b) a reminder phone call to confirm study visits; c) 24/7 access to the study team during 
participation; and d) establishing appropriate rapport such that the participant feels motivated to return. Participant 
will also receive a gift card for each visit as compensation. These strategies should minimize missing data and 
improve data validity. 
Preparing, dispensing and recording study supplements by IDS Supplies for each participant will be prepared 
by IDS following randomization. Instructions on use and storage will be provided in writing. Participants will be 
asked to keep track of missed dose. Unused materials will be returned at the next visit, recorded and destroyed by 
IDS. IDS will maintain a Study Drug Accountability log for each participant, which will record participant ID, 
randomization code, medication ID, dates of medication dispensed, returned, missed dose, number of capsules 
returned, and medication destruction. 

Data and biological sample collection and storage All data (participant information, questionnaire responses, 
values of biological samples and others) will be stored in a REDCap database. REDCap is a HIPAA-compliant, 
highly-secure, and intuitive-to-use web-based application designed to capture and store data for clinical research, 
including questionnaire data from research participants. Data will be exported into a SAS data set for analysis. 
Data integrity will be evaluated using descriptive statistics (e.g., means, standard deviations, frequencies, percent, 
range) appropriate for measurement levels. Checks for implausible or out-of-range values, distributional forms, and 
missingness will be performed. 
For biological samples, a research assistant will retrieve the urine and blood samples from the Clinic within 1 hour 
after the participant’s visit and deliver to the Xing lab. The total volume of the urine sample will be recorded to the 
closest 10 mL. The urine samples will be split into different aliquots and stored at – 80ºC. The blood samples will 
be processed into plasma, buffy coat and red blood cells and stored at – 80ºC. Detailed information of these 
samples, including participant ID, visit #, sample information, and missed dosing or sample(s), will be recorded in 
the REDCap database. 
Minimizing potential risk to confidentiality: Any concerns related to the intervention and privacy will be shared 
with the PI and every effort will be made to protect the participants’ information during the study. All study personnel 
are accustomed to maintaining and ensuring patient confidentiality in the course of their work. In addition, all study 
personnel are highly trained in research procedures and in issues regarding protection of participants’ rights and 
privacy. All members of the research team, including the PI, coinvestigators, study coordinator, data collectors, 
research assistants, data manager, and all students associated with the project will complete UF-mandated human 
subject training prior to study commencement. Participants’ identities will be protected through the following 
measures: consent forms will be stored behind a locked door and in a locked filing cabinet accessible only by the 
PI, and all identifying information will be stored in a separate, secured location from data that is collected during 
the study. Access to locked files will be restricted to essential personnel only. In addition to consent and 
identification files that are secured, all data files will be coded in a manner that makes identification of the 
participants extremely unlikely. Indeed, participants will be given a numerical ID code to ensure that inadvertent or 
unauthorized identification does not occur. Data will receive additional layers of security because the whole 
building, floor, and office in which locked records are maintained have restricted, keyed access. The anonymous 
codes assigned to participants will be verified and maintained by Dr. Salloum throughout the study, and codes with 
names will be provided only to meet federal guidelines applicable to the facility. Data will be entered into a REDCap 
database developed for the project. REDCap (Research Electronic Data Capture) is a secure, HIPAA-aligned web-
based application designed to support traditional case report form data capture. REDCap’s automated export 
procedure will be utilized to export data into a SAS data set for analysis. Our research coordinator will conduct the 
screening of potential participants working closely with the clinical staff. The research coordinator will meet with Dr. 
Salloum weekly to discuss study progress. 
 
Environment Assessment (EA): An Environmental Assessment is not required because the action requested 
qualifies for a categorical exclusion per 21 CFR 25.31(e). To the applicant’s knowledge, no extraordinary 
circumstances exist per 21 CFR 25.15(d). 
 
7. POSSIBLE DISCOMFORTS AND RISKS 
Possible discomforts and risks from taking kava supplement are minimal. Preliminary data from a previous human 
study did not report any adverse events due to the consumption of kava supplementation. Because there is a 
potential for kava to affect the function of the liver through drug-herb interactions (<0.3 cases per million dosages), 
we will exclude any subjects with liver conditions and will monitor liver function during and after participants are 
receiving the intervention. AB-free kava (a kava preparation free of flavokavains A and B, the potential hepatotoxic 
ingredients in kava [26]) will be used the study as well, which is expected to have an improved safety profile. In the 
event that serum liver enzymes become elevated (3 times the normal range, which is considered as mild elevation 
clinically), participants will be notified immediately and retested in the next 48 – 72 hours. If increases to >5 x ULN, 
the study drug will be discontinued and participant referred for further clinical evaluation and treatment. For any 
increase in ALT, AST, ALP or total bilirubin >3 x ULN associated with fatigue, nausea, vomiting, right upper 
quadrant pain or tenderness, fever and/or rash, the study drug will be discontinued and participant referred for 
further clinical evaluation and treatment. No severe adverse effects have been detected in the pilot kava trial and 
the recent GAD trial. Subjects have the potential to experience other side effects like digestive upset, headache, 
and dizziness. There is minimal risk associated with blood draws, which will be performed by certified professionals. 
Similarly, there are potential risks to confidentiality for participants in this study. However, these risks are minimal 

given our procedures to protect against these risks. No other discomforts and risks (psychological, social, and/or 
economic), study participants are expected to encounter.  
 
Given kava’s potential neurological functions, we have built in a Modified Ask Suicide-Screening Questions (MASQ) 
form to assess the suicide risk. This questionnaire will be evaluated in real time by a trained study coordinator and 
can refer the patient to mental services if needed. Should such an emergency arise (statement or demonstration 
of active suicidal ideation), standard of care clinic procedures will be followed. Specifically, Alachua County Crisis 
Center would be called (352-264-6789) to have the patient evaluated in clinic (they send a staff member to clinic 
to see the patient) or the patient would be sent directly to a psychiatric facility (Vista or Meridian) for further 
evaluation and management either voluntarily or under a Baker Act. Additionally, all patients will be provided with 
resources for mental health help. The following numbers will be provided to patients in the ICF as well as upon 
request, UF psychiatry clinical sites (352) 265-4357., the Alachua County Crisis Center (352) 264-6789, and the 
Suicide and Crisis Lifeline 988 number. Kava use may result in sedation that the participant should not operate 
heavy instruments and should drive with care within 2 h after AB-free kava use, until they know how it affects them 
although such a risk is extremely low at the proposed dosage regimen. Additionally, collection of relevant medical 
history should be obtained at screening. Relevant is defined as any diagnosis of depression. 
 
There are no potential financial risks that study participants may incur given the trial is free of charge to participants 
with all supplies provided and incentives are provided as well. Additionally, our clinical team has ample experience 
to protect against or minimize potential unexpected discomforts and risks.  
 
8. POSSIBLE BENEFITS 
 
There are several potential benefits from the study. AB-free kava may provide individuals randomized to the AB-
free kava group a decrease in the urge to smoke, thereby making it an effective smoking cessation treatment. It 
may also improve the quality of sleep and reduce stress. This could be an effective, low-cost strategy to help people 
quit smoking and improve the quality of life. The risks for this study, as discussed above, are minimal and are far 
outweighed by the potential benefits to be gained regarding smoking cessation and the improvement in quality of 
life. 
 
Regardless of the findings, this study will make a significant contribution to the literature in the field of supportive 
care. Indeed, it will fill a vital gap in the literature regarding the ability of kava to reduce the urge to smoke as well 
as reduce stress and improve sleep. In addition, this study will provide data for manuscripts that can be published 
in peer-reviewed, high impact journals, as well as manuscripts that can be published in lay journals for the public. 
Finally, this study will yield information that the investigators will disseminate at local, regional, state, and national 
meetings and will serve as the basis for conducting a follow-up, Phase III randomized control trial. In all 
presentations, we will use necessary scientific language about inclusion/exclusion criteria of the trial and about 
potential interaction with other widely used medications (i.e., acetaminophen) to minimize the risk of abuse. 
 
9. ADVERSE EVENTS/UNANTICIPATED PROBLEMS 
 
To minimize and closely monitor any potential Adverse Events/Unanticipated Problems, we will exclude 
individuals with elevated risk for hepatotoxicity, provide additional education, and closely monitor liver functions 
during the treatment period with 4 and 8-week follow-ups, which will be sufficient even based on kava’s reported 
hepatotoxic cases [46]. Specifically, participants will be asked to control alcohol use and refrain from products 
containing acetaminophen through the study period. They will be provided with a reference list of medications that 
contain acetaminophen. ALT, AST, ALP, and total bilirubin will be assessed at every visit to ensure any adverse 
effects/risks identified and addressed. Alcohol use will be assessed via questionnaires (self-report). The AE 
collection period will start at Visit 1 when the first pills are received and end at Week 12. In addition to all 
serious adverse events (grade III and above), only non-serious adverse events (less than grade III) that are 
possible, probable, or definitely related will be reported into the study REDCap. Dr. Malaty or Dr. Orlando will 
supervise liver screening and safety monitoring. Participants with an increase in liver biochemistry will be referred 
to clinical services at UF for further evaluation to minimize the risk with plan detailed below. Dr. Malaty or Dr. 
Orlando, in consultation with Dr. Firpi (co-I and a hepatologist with clinical expertise in liver safety monitoring), will 
report any relevant adverse events to the Institutional Review Board (IRB) that meet the boards reporting 
requirements. 

 
10. STATISTICAL ANALYSIS PLAN 
 
Sample size determination: The sample size was estimated based on our primary biological signature endpoint 
data (TNE and PRKACA) from our pilot results. Using the pilot result of TNE as an example, the ratio of geometric 
mean of TNE after one week kava treatment is 0.68 with a standard error of 0.06. By assuming the placebo group 
exhibits 15% of the treatment effect, which is a consensus estimate in the literature [47, 48], and the same standard 
error as in the kava treatment group, the standardized effect size (Cohen’s d) is d=1.01. Similarly, the Cohen’s d 
for PRKACA is 0.89. Since in our proposed study, we will repeatedly measure these biomarkers of the same 
participant, we further assume the same Kava effect from week one through week four. By (i) varying within-
participant correlation rho = 0, 0.2, 0.4, 0.6, and 0.8; (ii) at Bonferroni-corrected alpha level 2.5%(5%/2), and (iii) 
using a linear mixed model, 60 participants (30 per group) are needed to have at least 90% power for both TNE 
and PRKACA. By further assuming an 80% retention rate, which is the rate in similar studies [49], we plan to recruit 
76 participants (38 per group).  
Data analysis plan: 
Principle All data (questionnaires and biomarkers) will be checked for out-of-range values and normality. Decisions 
regarding parametric vs nonparametric statistics and data transformation will be based on such results. Participants 
who received at least one dose of AB-free kava treatment or placebo, and have at least one more visit beyond the 
baseline visit will be considered as evaluable. 
Missing data consideration We expect to have three scenarios for participants with respect to missing data. (1) 
Participants complete all visits and have no missing outcomes. They will be included in the statistical analysis. (2) 
Some participants may not complete all visits, but have outcomes for at least one visit after the baseline visit. These 
participants will be included in the statistical analysis as well. The missing outcomes will be handled by either the 
Last Observation Carry Forward (LOCF) technique or linear mixed model for longitudinal data analysis (see below 
for details). (3) Participants do not complete the first two visits after randomization. They will be excluded from data 
analysis and we will replace these participants (also see replacement plan section).  An enrolled participant will be 
replaced if s/he (i) is not involved in the baseline visit, or (ii) is only involved in the baseline visit not in any of the 
next five visits. Such cases are expected to be no more than 20%. 
Account for spurious data: All data (questionnaires and biomarkers) will be checked for out-of-range values and 
normality. If any spurious data (outliers) were identified, we will fit nonparametric statistical models to assess the 
robustness of our primary parametric data analysis. 
Replacement Plan If a participant for any reason leaves the study, the study team will recruit a new participant to 
replace the study subject that is no longer in the study.  
Primary Endpoint – Compliance Such information is critical for data interpretation and future clinical trial 
improvement. We will evaluate trial compliance in three ways as we have done in the pilot trial [38]: i) self-report of 
missed doses from participant diary; ii) returned pill counts by IDS pharmacy; and iii) urinary detection of 
dihydromethysticin (DHM) in participants during AB-free kava exposure since DHM is kava-specific [45]. In 
combination with the exit interview, the results will provide knowledge of the feasibility of AB-free kava use and 
potential issues among smokers with current treatment regimen. 
Endpoints for Tobacco Cessation, Stress Reduction and Sleep Improvement – tobacco dependence 
(questionnaires), tobacco use (urinary TNE, total nicotine equivalents), stress (questionnaires), stress biomarkers 
(plasma PRKACA, plasma cortisol and urinary TCE, total cortisol equivalents), sleep (questionnaires and Fitbit 
measures), and sleep biomarkers (urinary 6-hydroxymelatonin and urinary N-acetyl serotonin, NAS). 
Longitudinal data analysis To study the relationship between longitudinal outcomes and treatment effect, we will 
fit linear mixed effects models with subject specific random effects to account for within subject correlation, using 
R software lmer package. Linear mixed model can accommodate missing outcomes if they are missing at random. 
Baseline outcomes and covariates including age, sex, race, smoking status will be adjusted to account for 
confounding effects. Urinary TNE, one key endpoint, will be used to describe how the statistical models test our 
working hypotheses. The other measurements will follow the same model. 
Hypothesis 1: active kava treatment (week 0 – week 4) is effective in reducing TNE as compared to the 
placebo group. To test this hypothesis, we will fit the following linear mixed model: 

 
𝑦𝑦𝑖𝑖𝑖𝑖= 𝜇𝜇+ 𝛼𝛼𝑖𝑖+ 𝛽𝛽𝑧𝑧𝑖𝑖𝑡𝑡+ ෍𝛾𝛾𝑙𝑙𝑥𝑥𝑖𝑖𝑖𝑖
𝐿𝐿
𝑙𝑙=0
+ 𝜀𝜀𝑖𝑖𝑖𝑖, 𝛼𝛼𝑖𝑖~𝑁𝑁(0, 𝜎𝜎0
2), 𝜀𝜀𝑖𝑖𝑖𝑖~𝑁𝑁(0, 𝜎𝜎2) 
(1) 
where 𝑦𝑦𝑖𝑖𝑖𝑖 is the outcome variable (e.g., TNE) for subject 𝑖𝑖 and week 𝑡𝑡 (0 ≤𝑡𝑡≤4 weeks); 𝜇𝜇 is the intercept 
term; 𝛼𝛼𝑖𝑖~𝑁𝑁(0, 𝜎𝜎0
2) is the random effect with variance term 𝜎𝜎0
2 for subject 𝑖𝑖; 𝑧𝑧𝑖𝑖 is the treatment indicator for 
subject 𝑖𝑖 with 𝑧𝑧𝑖𝑖= 0 for the placebo group, and 𝑧𝑧𝑖𝑖= 1 for the kava group; 𝛽𝛽 is the slope (TNE change per unit 
dose of kava per week) of the treatment effect compare to the placebo group; 𝑥𝑥𝑖𝑖𝑖𝑖 is the 𝑙𝑙𝑡𝑡ℎ covariates for 
subject 𝑖𝑖 with 𝑙𝑙= 0 for baseline level of the outcome measurements (e.g. baseline TNE) and 𝑙𝑙= 1,2, … , 𝐿𝐿 for 
𝐿𝐿 covariates (e.g., age, sex, race, smoking history, etc); 𝜀𝜀𝑖𝑖𝑖𝑖~𝑁𝑁(0, 𝜎𝜎2) is the error term with variance 𝜎𝜎2. In 
Equation (1), we will perform the statistical hypothesis testing (H0: 𝛽𝛽= 0) to provide its p-value, point estimate 
and confidence interval. A significant p-value will indicate that the kava treatment significantly reduces TNE 
during week 0 through week 4 compared to the placebo group.  
If we observe that the trajectory of kava’s effect through weeks 0, 1, 2, and 4 is not linear, we will only 
consider observations at week 0 and week 4 to test Hypothesis 1, employ linear regression models. 
Exploratory hypothesis 2: kava has a sustainable effect in reducing TNE in week 4 – week 12. We will 
test whether the kava effect (week 0 – week 4) can be extended to the follow-up period week 4 – week 12, 
when kava treatment is absent. The following two sub-hypotheses will be examined: 
2a: kava’s effect will sustain to the follow-up period. To test this hypothesis, we will only consider the kava 
treatment arm with 4 ≤𝑡𝑡≤12 weeks. We will fit the following linear mixed model: 
 
𝑦𝑦𝑖𝑖𝑖𝑖= 𝜇𝜇+ 𝛼𝛼𝑖𝑖+ 𝛽𝛽1𝕀𝕀(𝑡𝑡= 8) + 𝛽𝛽2𝕀𝕀(𝑡𝑡= 12) + ෍𝛾𝛾𝑙𝑙𝑥𝑥𝑖𝑖𝑖𝑖
𝐿𝐿
𝑙𝑙=0
+ 𝜀𝜀𝑖𝑖𝑖𝑖, 𝛼𝛼𝑖𝑖~𝑁𝑁(0, 𝜎𝜎0
2), 𝜀𝜀𝑖𝑖𝑖𝑖~𝑁𝑁(0, 𝜎𝜎2) 
(3) 
where 𝜇𝜇 is the kava treatment effect at week 4; 𝛽𝛽1 is the kava treatment effect at week 8 compared to week 
4; 𝛽𝛽2 is the kava treatment effect at week 12 compared to week 4; the rest of the parameters have the same 
interpretation as Equation (1). In Equation (3), we will perform the statistical hypothesis testing (H0: 𝛽𝛽1 ≤0 vs 
HA: 𝛽𝛽1 > 0, and H0: 𝛽𝛽2 ≤0 vs HA: 𝛽𝛽2 > 0). Rejecting the null hypothesis will imply 𝛽𝛽1 > 0 or 𝛽𝛽2 > 0, which 
indicates that the kava effect is not sustainable. In other words, TNE level will go up and the participants are 
likely to relapse. Failing to reject the null hypothesis will imply that the TNE level stays steady and the kava 
treatment effect likely sustains through week 8 and week 12. We will provide their p-value, point estimates 
and confidence intervals. 
2b: the extended kava effect is superior to placebo. To evaluate this hypothesis, we will directly apply 
Equation (1) in Hypothesis 1, but treat week 4 as baseline, and week 12 as follow-up. Under this scenario, 𝛽𝛽 
is the slope of the extended kava effect (week 4 – 12) compared to the placebo group. We will perform the 
statistical hypothesis testing (H0: 𝛽𝛽= 0) to provide its p-value, point estimate and confidence interval. A 
significant p-value will indicate that the extended kava effect significantly reduces TNE during the follow-up 
period (week 4 through week 12) compared to the placebo group, indicating kava’s sustainable effect. 
 
H B  c o rtis o l
L B  c o rtis o l
0
2 5
5 0
7 5
T N E  re d u c tio n  %
p  =  0 .1 4
A

Exploratory 
hypothesis 
3: 
tobacco reduction by AB-free 
kava is potentially mediated via 
reductions in plasma PRKACA, cortisol, urinary TCE, NAS or 6-hydroxymelatonin. Our pilot data suggested 
that smokers with higher baseline levels of cortisol appeared to have more reductions in TNE upon AB-free kava 
use (Fig. 2A) while the extents of reduction in TNE correlate positively with the reductions in plasma cortisol (Fig. 
2B). Although the difference and correlation were not statistically significant, these results support the potential 
association between stress reduction and tobacco use reduction. We therefore hypothesize that changes in plasma 
PRKACA, plasma cortisol, urinary TCE, urinary NAS or urinary 6-hydroxymelatonin are potential mediators for the 
effect of AB-free kava in reducing TNE. To test this hypothesis, we will perform mediation analysis, where TNE 
reduction is the outcome variable, AB-free kava intervention is the predictor, plasma PRKACA, cortisol, urinary 
TCE, NAS, or 6-hydroxymelatonin is the mediator, adjusting for age, sex, race, and smoking status as covariates. 
The direct effects, indirect effects, and mediation proportion will be determined using the R mediation package. 
Their p-values and 95% confidence intervals will be reported. Such hypothesis, if tested positive, will provide 
mechanistic insight – whether AB-free kava may induce TNE reduction via relieving stress or improving sleep. 
Exploratory hypothesis 4: the biological signature and biobehavioral changes are related. For a pair of 
biological signature and associated behavior (e.g., TNE reduction and tobacco dependence reduction, PRKACA 
reduction and stress reduction, or NAS increase and sleep improvement), we will compute their Pearson correlation 
and the corresponding p-value. This correlation analysis will be repeated for all biological signatures with the 
corresponding biobehavioral pairs. Such analyses will be performed both dependent and independent of kava 
treatments. 
Plan for conducting an interim analysis and criteria for stopping rules: when 25% participants complete the 
study, safety data of all participants will be analyzed by DISC independently to determine whether AB-free kava 
intervention has any potential risk. The same practice will be implemented at 50% and 75% completion. If the 
adverse events are significantly higher in the AB-free kava arm than the placebo arm, the trial will be suspended to 
discuss with FDA and Florida Department of Health to determine whether the trial should stop. 
 
11. STUDY MONITORING 
 
Data and Safety Monitoring Plan Once a participant is enrolled, continuous monitoring will be conducted by Drs. 
Salloum and Firpi (PI and Co-Is), in conjunction with other investigators as well as IRB. Any serious adverse events 
as well as unanticipated problems involving risks to participants or others, will be reported to IRB, FDOH, and FDA. 
Our monitoring plan includes the following measures: 
1. Monitor adverse events, study progression, and data quality issues; consider factors external to the study 
when interpreting data, such as new scientific or therapeutic developments that may have an effect on the 
safety of the participants or the ethics of the study; and maintain confidentiality during all phases of the trial. 
2. Participants will be assessed for ALT, AST, ALP and total bilirubin at baseline, week 1, 2, 4, 8 and 12 to 
monitor potential acute or delayed hepatotoxic risk. Participants, whose ALT, AST, ALP or total bilirubin 
increases > 3 x the upper limit of normal (ULN) but ≤ 5 x ULN, will retest after 48 to 72 hours. If increases 
to >5 x ULN, the study drug will be discontinued and participant referred for further clinical evaluation and 
treatment. For any increase in ALT, AST, ALP or total bilirubin >3 x ULN associated with fatigue, nausea, 
vomiting, right upper quadrant pain or tenderness, fever and/or rash, study drug will be discontinued and 
participant referred for further clinical evaluation. 
3. The study will undergo regular audits by a Data Integrity and Safety Committee (details in Section 12). 
 
12. DATA INTEGRITY AND OVERSIGHT 
 
Per UF IRB requirements, the PI will be personally responsible for conducting and supervising the conduct of 
human subjects research by “protecting the rights, safety, and welfare of subjects under the investigator’s care.” 
The PI will also ensure that all the research conducted is done so in an ethical manner and in accordance with all 
federal, state, and local laws and regulations, institutional policies, and the requirements of the IRB. The PI has 
voluntarily accepted these responsibilities and will fully comply with these requirements, as outlined in the UFHCC 
Guidance: Principal Investigator Responsibilities and Oversight. 
 
Fig. 2. Reduction of TNE among high baseline (HB) and low baseline (LB) TCE subgroups 
via one-tailed t-test (A) and correlation of TNE reduction and plasma cortisol reduction
among HB cortisol subgroup (B). 

The PI will be primarily responsible for continuous monitoring of adverse events, unanticipated problems, protocol 
violations, and other immediate protocol issues. The PI or their designee will collect information on subjects enrolled 
through the use of electronic or paper source documents, CRFs, and Informed Consent forms. 
 
The PI will be responsible for ensuring the accuracy, completeness, legibility, and timeliness of the data reported.  
All source documents will be completed in a neat, legible manner to ensure accurate interpretation of data.  The 
study team will maintain adequate case histories of study subjects, including accurate case report forms (CRFs), 
and source documentation. 
 
Data Integrity and Safety Committee (DISC). This protocol will be reviewed and monitored by the University of 
Florida Health Cancer Center Data Integrity and Safety Committee (UFHCC DISC) in accordance with their policies 
and procedures.  They will review and monitor study progress, toxicity, safety and other data from this trial. 
Questions about subject safety or protocol performance will be addressed with the sponsor-investigator, statistician 
and study team members. Should any major concerns arise, the DISC will offer recommendations regarding 
whether or not to suspend the trial. 
UFHCC DISC data and safety monitoring activities include:  
• 
Review of clinical trial conducted for progress and safety  
• 
Review of all adverse events requiring expedited reporting as defined in the protocol  
• 
Review of reports generated by data quality control review process  
• 
Notification of the sponsor-investigator of recommended action  
• 
Notification of sites coordinated by the UFHCC of adverse events requiring expedited reporting and 
subsequent committee recommendations for study modifications 
 
In compliance with the UFHCC data and safety monitoring plan, the PI will provide a Data Integrity and Safety 
Committee Report to DISC at the predetermined timelines for the level of risk category assigned during the initial 
SRMC CCPSP (Scientific Review and Monitoring Committee Cancer Control and Population Sciences Panel) 
review, which occurs prior to initial IRB approval. 
 
UFHCC investigator-initiated protocols will be classified into one of the following categories of risk by the SRMC 
CCPSP (see SRMC manual for further details): 
 
Level 1 – Low risk Investigator Initiated interventional trials. 
Level 2 – Moderate risk Investigator Initiated or externally sponsored interventional (such as drug, biologic or 
device) trials using FDA approved or commercially available compounds or interventions. 
Level 3 – High risk Investigator Initiated or externally sponsored interventional trials (such as investigator-
sponsored INDs, Phase I trials, studies requiring biosafety approval, or other areas that may be designated by NIH 
as high risk). 
Level 4 – Complex trials involving very high risk to subjects and a high level of complexity such as first in human 
or gene transfer studies. 
 
The risk level assigned by the SRMC CCPSP will determine the appropriate level of DISC monitoring required, with 
increased monitoring required for higher-risk trials.  
 
 
13. DATA MANAGEMENT 
 
Data collection for the trial will be managed through REDCap and stored on secure UF servers. Questionnaire data 
forms will be subject to computerized range and consistency checks. Biological data will be subject to computerized 
range and consistency checks as well. Initial examination of data will include descriptive statistics, frequency 
distributions, and histograms in order to identify outliers, missing data and check data source adequacy. This 
process will be supervised jointly by the PI and the lead statistician. Data will be periodically converted to SAS and 
R data types. Any entry error and/or inconsistency will be discussed during meetings with the study team. Quarterly 
statistical summaries and progress reports will be generated by the statistician for review by all investigators. To 
ensure participant confidentiality, all personal identifiers will be expunged from the data set. 

 
14. CONFLICT OF INTEREST 
 
The funded grant will evaluate AB-free kava's potential to help smokers reduce tobacco use and risk of lung cancer. 
The AB-free kava product to be evaluated is developed by Thorne, based on the IPs owned by Kuality Herbceutics 
(KH). KH has an estimated value of $400,000 on the basis of the IP and the investment to date, which is to support 
IP protection. There is no profit or product from KH yet. Chengguo Xing (the PI of this grant) owns 55% of the stock 
of KH. He also provides consultation to KH for its strategy on development. 
Describe any conflict of interest relevant to this protocol.  If none to note, please note “Not applicable”. 
 
15. APPENDICES 
 
A. Proposed measures for tobacco use, craving, addiction, stress, and insomnia 
B. Schedule of events  

16. REFERENCES 
 
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Toxicol. 2003;41:821-829. 
23.  Martin AC, Johnston E, Xing C, Hegeman AD. Measuring the chemical and cytotoxic variability of commercially 
available kava (Piper methysticum G. Forster). PloS one. 2014;9:e111572. 
24.  Lebot V, Do TK, Legendre L. Detection of flavokavins (A, B, C) in cultivars of kava (Piper methysticum) using high 
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25.  Jhoo JW, Freeman JP, Heinze TM, Moody JD, Schnackenberg LK, Beger RD, Dragull K, Tang CS, Ang CY. In vitro 
cytotoxicity of nonpolar constituents from different parts of kava plant (Piper methysticum). Journal of agricultural and food 
chemistry. 2006;54:3157-3162. 
26.  Narayanapillai SC, Leitzman P, O'Sullivan MG, Xing C. Flavokawains a and B in kava, not dihydromethysticin, 
potentiate acetaminophen-induced hepatotoxicity in C57BL/6 mice. Chemical research in toxicology. 2014;27:1871-1876. 
27.  Zhou P, Gross S, Liu JH, Yu BY, Feng LL, Nolta J, Sharma V, Piwnica-Worms D, Qiu SX. Flavokawain B, the 
hepatotoxic constituent from kava root, induces GSH-sensitive oxidative stress through modulation of IKK/NF-kappaB and 

MAPK signaling pathways. FASEB journal : official publication of the Federation of American Societies for Experimental 
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28.  Leitzman P, Narayanapillai SC, Balbo S, Zhou B, Upadhyaya P, Shaik AA, O'Sullivan MG, Hecht SS, Lu J, Xing C. 
Kava blocks 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone-induced lung tumorigenesis in association with reducing O6-
methylguanine DNA adduct in A/J mice. Cancer Prev Res. 2014;7:86-96. 
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30.  Tang SN, Zhang J, Jiang P, Datta P, Leitzman P, O'Sullivan MG, Jiang C, Xing C, Lu J. Gene expression signatures 
associated with suppression of TRAMP prostate carcinogenesis by a kavalactone-rich Kava fraction. Molecular 
carcinogenesis. 2016;55:2291-2303. 
31.  Narayanapillai SC, Balbo S, Leitzman P, Grill AE, Upadhyaya P, Shaik AA, Zhou B, O'Sullivan MG, Peterson LA, Lu 
J, Hecht SS, Xing C. Dihydromethysticin from kava blocks tobacco carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-
butanone-induced lung tumorigenesis and differentially reduces DNA damage in A/J mice. Carcinogenesis. 2014;35:2365-
2372. 
32.  Raju SRM, J.; Nelson, R.; McCurdy, C. R.; Mathews, C.A.; Xing, C.; Sharma, A. Clinical Pharmacokinetics of 
Kavalactones after Oral Dosing of Standardized Kava Extract in Healthy Volunteers. J Ethnopharmacology. 2022;Under 
review. 
33.  Sarris J, Stough C, Bousman CA, Wahid ZT, Murray G, Teschke R, Savage KM, Dowell A, Ng C, Schweitzer I. Kava 
in the Treatment of Generalized Anxiety Disorder: A Double-Blind, Randomized, Placebo-Controlled Study. Journal of 
clinical psychopharmacology. 2013. 
34.  Sarris J, Stough C, Teschke R, Wahid Z, Bousman C, Murray G, Savage K, Mouatt P, Ng C, Schweitzer I. Kava for the 
Treatment of Generalized Anxiety Disorder RCT: Analysis of Adverse Reactions, Liver Function, Addiction, and Sexual 
Effects. Phytotherapy research : PTR. 2013. 
35.  Baric H, Dordevic V, Cerovecki I, Trkulja V. Complementary and Alternative Medicine Treatments for Generalized 
Anxiety Disorder: Systematic Review and Meta-analysis of Randomized Controlled Trials. Advances in therapy. 
2018;35:261-288. 
36.  Ooi SL, Henderson P, Pak SC. Kava for Generalized Anxiety Disorder: A Review of Current Evidence. Journal of 
alternative and complementary medicine. 2018. 
37.  Yerger VB, Wertz M, McGruder C, Froelicher ES, Malone RE. Nicotine replacement therapy: perceptions of African-
American smokers seeking to quit. Journal of the National Medical Association. 2008;100:230-236. 
38.  Wang YN, S.; Tessier, K.; Strayer, L.; Upadhyaya, P.; Hu, Q.; Kingston, R.; Salloum, R. G.; Lu, J.; Hecht, S.S.; 
Hatsukami, D.; Fujioka, N.; Xing, C. The Impact of One-week Dietary Supplementation with Kava on Biomarkers of 
Tobacco Use and Nitrosamine-based Carcinogenesis Risk among Active Smokers. Cancer Prev Res. 2020;13:483-492. 
39.  Yancey AK, Ortega AN, Kumanyika SK. Effective recruitment and retention of minority research participants. Annu 
Rev Public Health. 2006;27:1-28. 
40.  Kreuter MW, Lukwago SN, Bucholtz RD, Clark EM, Sanders-Thompson V. Achieving cultural appropriateness in 
health promotion programs: targeted and tailored approaches. Health Educ Behav. 2003;30:133-146. 
41.  Fisher CL, Wright KB, Rising CJ, Mullis MD, Afanaseva D, Burke-Garcia A, Cai X. Culturally Appropriate Breast 
Cancer and Environmental Risk Messages: Targeting Racially and Ethnically Diverse Mothers. J Cancer Educ. 2021;36:284-
293. 
42.  Glaser BG, Strauss AL: Discovery of grounded theory: Strategies for qualitative research, Routledge; 2017. 
43.  Strauss A, Corbin J: Basics of qualitative research, Sage publications; 1990. 
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45.  Wang YE, S.; Stacy, H.; Narayanapillai, S.; Sharma, A.; Fujioka, N.; Haddad, L.; McLaughlin, J.; Avery, B. A.; Xing, 
C. A stable isotope dilution tandem mass spectrometry method of major kavalactones and its applications. PloS one. 
2018;13:e0197940. 
46.  Teschke R. Kava hepatotoxicity--a clinical review. Annals of hepatology. 2010;9:251-265. 
47.  Oncken C, Gonzales D, Nides M, Rennard S, Watsky E, Billing CB, Anziano R, Reeves K. Efficacy and safety of the 
novel selective nicotinic acetylcholine receptor partial agonist, varenicline, for smoking cessation. Arch Intern Med. 
2006;166:1571-1577. 
48.  Nides M, Oncken C, Gonzales D, Rennard S, Watsky EJ, Anziano R, Reeves KR. Smoking cessation with varenicline, a 
selective alpha4beta2 nicotinic receptor partial agonist: results from a 7-week, randomized, placebo- and bupropion-
controlled trial with 1-year follow-up. Arch Intern Med. 2006;166:1561-1568. 

49.  Thompson TP, Greaves CJ, Ayres R, Aveyard P, Warren FC, Byng R, Taylor RS, Campbell JL, Ussher M, Michie S, 
West R, Taylor AH. Factors associated with study attrition in a pilot randomised controlled trial to explore the role of 
exercise-assisted reduction to stop (EARS) smoking in disadvantaged groups. Trials. 2016;17:524. 
 
 
 

17. APPENDIX A:  
Proposed Measures For Tobacco Use, Craving, Addiction, Stress, And Insomnia 
 
 
Self-Reported Measures of Smoking Cigarettes 
 
 
To help us evaluate your cigarette use, we need to get an idea of what your smoking was like in 
the past________________ days. To do this, we would like you to fill out the attached calendar. 
Filling out the calendar is not hard! Try to be as accurate as possible. 
We recognize you won’t have perfect recall. That’s OKAY. 
 
WHAT TO FILL IN 
The idea is to record how many cigarettes you smoked for each day on the calendar. 
On days when you did not smoke cigarettes, not even one, you should write a "0." 
It’s important that something is written for every day, even if it is a 0". 
 
YOUR BEST ESTIMATE 
We realize it isn’t easy to recall things with 100% accuracy. 
If you are not sure whether you smoked 15 or 16 cigarettes or whether you smoked on a Thursday or a Friday, 
give it your best guess! What is important is that 15 or 16 cigarettes is very different from 1 cigarette. The goal is 
to get a sense of how frequently you smoked, how much you smoked, and your patterns of smoking. 
 
HELPFUL HINTS 
• 
If you have an appointment book, you can use it to help you recall your use. 
• 
Holidays such as Thanksgiving and Christmas are marked on the calendar to help you recall your 
smoking. Also, think about how much you smoked on personal holidays & events such as birthdays, 
vacations, or parties. 
• 
If you have regular patterns to your smoking, you can use these to help you recall your use. 
For example, some people may only smoke during social situations. 
 
COMPLETING THE CALENDAR 
A blank calendar is attached. Write in the number of cigarettes you smoked on each day. 
The time period we are talking about on the calendar is from______________ to __________________. 
In estimating the number of cigarettes you smoked, be as accurate as possible. 
 
DOUBLE CHECK THAT ALL DAYS ARE FILLED IN BEFORE RETURNING THE CALENDAR. 
Before you start look at the SAMPLE CALENDAR. 
✓ Instructions for Filling Out the Timeline Cigarette Use Calendar 

Fagerstrom Test for Nicotine Dependence 
 
1. How soon after you wake up do/did you smoke your first cigarette? 
1[ ]Within 5 minutes [3 points] 
2 [ ]6-30 minutes [2 points] 
3 [ ]31-60 minutes [1 point] 
4 [ ]After 60 minutes [0 points] 
2. Do/Did you find it difficult to refrain from smoking in places where it is forbidden, e.g., in 
church, at the library, in a cinema, etc.? 
1[ ]Yes [point ] 
2 [ ]No [0 points] 
3. Which cigarette would you hate most to give up? 
 
1[ ]The first one in the morning [1 point] 
2[ ] All others [0 points] 
4. 
How many cigarettes per day do/did you 
smoke? 
 
1[ ]10 or less [0 points] 
2[ ]11-20 [1 point] 
3[ ]21-30 [2 points] 
4[ ]31 or more [3 points] 
5. Do/did you smoke more frequently during the first hours after waking than during the rest of 
the day? 
1 [ ]Yes [1 point] 
2[ ]No [0 points] 
6. 
Do/did you smoke if you are so ill that you are in bed most of 
the day? 1[ ]Yes [1 point] 
2[ ]No [0 points] 

Modified Cigarette Evaluation Questionnaire 
 
 
 
If you have smoked since you last completed this questionnaire, please mark the number 
that best represents how smoking made you feel (1—not at all, 2—very little, 3—a little, 4— 
moderately, 5—a lot, 6—quite a lot, 7—extremely). 
1. 
Was smoking satisfying? 
2. 
Did cigarettes taste good? 
3. 
Did you enjoy the sensations in your throat and chest? 
4. 
Did smoking calm you down? 
5. 
Did smoking make you feel more awake? 
6. 
Did smoking make you feel less irritable? 
7. 
Did smoking help you concentrate? 
8. 
Did smoking reduce your hunger for food? 
9. 
Did smoking make you dizzy? 
10. 
Did smoking make you nauseous? 
11. 
Did smoking immediately relieve your craving for a cigarette? 
12. 
Did you enjoy smoking? 

 
 
Brief Questionnaire on Smoking Urges 
 
Indicate how much you agree or disagree with each of the following statements by placing a 
single checkmark (like this: [ ᤰ
ᤱ]) by a number ranging from 1 (strongly disagree) to 7 
(strongly agree). The closer you place your checkmark to one end or the other indicates the 
strength of your disagreement or agreement. Please complete every item. We are interested 
in how you are thinking or feeling right now as you are filling out this questionnaire. 
1. I have a desire for a cigarette right now. 
 
 
1 [ ] STRONGLY 
2 [ 
3 [ 
4 [ 
5 [ 
6 [ 
7 [ ] STRONGLY 
DISAGREE 
] 
] 
] 
] 
] 
AGREE 
 
2. Nothing would be better than smoking a cigarette right now. 
 
 
1 [ ] STRONGLY 
2 [ 
3 [ 
4 [ 
5 [ 
6 [ 
7 [ ] STRONGLY 
DISAGREE 
] 
] 
] 
] 
] 
AGREE 
 
3. If it were possible, I probably would smoke right now. 
 
 
1 [ ] STRONGLY 
2 [ 
3 [ 
4 [ 
5 [ 
6 [ 
7 [ ] STRONGLY 
DISAGREE 
] 
] 
] 
] 
] 
AGREE 
 
4. I could control things better right now if I could smoke. 
 
 
1 [ ] STRONGLY 
2 [ 
3 [ 
4 [ 
5 [ 
6 [ 
7 [ ] STRONGLY 
DISAGREE 
] 
] 
] 
] 
] 
AGREE 
 
5. All I want right now is a cigarette. 
 
1 [ ] STRONGLY 
2 [ 
3 [ 
4 [ 
5 [ 
6 [ 
7 [ ] STRONGLY 

DISAGREE 
] 
] 
] 
] 
] 
AGREE 
 
6. I have an urge for a cigarette. 
 
 
1 [ ] STRONGLY 
2 [ 
3 [ 
4 [ 
5 [ 
6 [ 
7 [ ] STRONGLY 
DISAGREE 
] 
] 
] 
] 
] 
AGREE 
 
7. A cigarette would taste good now. 
 
 
1 [ ] STRONGLY 
2 [ 
3 [ 
4 [ 
5 [ 
6 [ 
7 [ ] STRONGLY 
DISAGREE 
] 
] 
] 
] 
] 
AGREE 
 
8. I would do almost anything for a cigarette now. 
 
 
1 [ ] STRONGLY 
2 [ 
3 [ 
4 [ 
5 [ 
6 [ 
7 [ ] STRONGLY 
DISAGREE 
] 
] 
] 
] 
] 
AGREE 
 
9. Smoking would make me less depressed. 
 
 
1 [ ] STRONGLY 
2 [ 
3 [ 
4 [ 
5 [ 
6 [ 
7 [ ] STRONGLY 
DISAGREE 
] 
] 
] 
] 
] 
AGREE 
 
10. I am going to smoke as soon as possible. 
 
 
1 [ ] STRONGLY 
2 [ 
3 [ 
4 [ 
5 [ 
6 [ 
7 [ ] STRONGLY 
DISAGREE 
] 
] 
] 
] 
] 
AGREE 
 

 
 
 
 
 
l. In the last month, how often have you been upset because of something that 
happened unexpectedly? 
 
2. In the last month, how often have you felt that you were unable to control the important 
things in your life? 
 
3. In the last month, how often have you felt nervous and stressed? 
 
4. In the last month, how often have you felt confident about your ability to handle 
your personal problems? 
 
5. In the last month, how often have you felt that things were going your way? 
 
6. In the last month, how often have you found that you could not cope with all the 
things that you had to do? 
 
7. In the last month, how often have you been able to control irritations in your life? 
 
8. In the last month, how often have you felt that you were on top of things? 
 
9. In the last month, how often have you been angered because of things that happened 
that were outside of your control? 
 
10. In the last month, how often have you felt difficulties were piling up so high that 
you could not overcome them? 
 
 
 
 
131 
Perceived Stress Scale 
For each question choose from the following alternatives: 
0 - never 
1 - almost never 
2 - sometimes 
3 - fairly often 
4 - very often 

Insomnia Severity Scale  
Insomnia 
Severity 
Index 
The Insomnia Severity Index has seven questions. The seven answers are added up to get a total 
score. When you have your total score, look at the 'Guidelines for Scoring/Interpretation' below to see 
where your sleep difficulty fits. 
For each question, please CIRCLE the number that best describes your answer. 
Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s). 
 
Insomnia Problem 
None 
Mild 
Moderate 
Severe 
Very Severe 
1. Difficulty falling asleep 
0 
1 
2 
3 
4 
2. Difficulty staying asleep 
0 
1 
2 
3 
4 
3. Problems waking up too early 
0 
1 
2 
3 
4 
 
4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern? 
Very 
Satisfied 
Satisfied 
Moderately 
Satisfied 
Dissatisfied 
Very 
Dissatisfied 
0 
1 
2 
3 
4 
 
5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality 
of your life? Not at all 
 
Noticeable 
A Little 
Somewhat Much 
Very Much 
Noticeable 
0 
1 
2 
3 
4 
 
6. How WORRIED/DISTRESSED are you about your current   
sleep problem? Not at all 
 
Worried 
A Little 
Somewhat Much 
Very Much 
Worried 
0 
1 
2 
3 
4 
 
7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning 
(e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, 
etc.) CURRENTLY? 
Not at all 
Interfering 
A Little 
Somewhat 
Much 
Very Much 
Interfering 
0 
1 
2 
3 
4 
 
 

Guidelines for Scoring/Interpretation: 
Add the scores for all seven items (questions 1 + 2 + 3 + 4 + 5 +6 + 7) = 
 
your total score Total score categories: 
0–7 = No clinically significant insomnia 
8–14 = Subthreshold insomnia 
15–21 = Clinical insomnia (moderate 
severity) 22–28 = Clinical insomnia 
(severe) 
Used via courtesy of www.myhealth.va.gov with permission from Charles M. Morin, Ph.D., Université Laval 
 
 
 

Modified Pittsburgh Sleep Quality Index (MPSQI) 
 
Modified Pittsburgh Sleep Quality Index (PSQI) 
 
Instructions: The following questions relate to your usual sleep habits during the past month only. 
Your answers should indicate the most accurate reply for the majority of days and nights in the 
past month.  
Please answer all questions. 
1. During the past month, what time have you usually gone to bed at night? 
 
 
2. During the past month, how long (in minutes) has it usually taken you to fall asleep each night? 
 
 
3. During the past month, what time have you usually gotten up in the morning? 
 
 
4. During the past month, how many hours of actual sleep did you get at night? (This may be 
different than the number of hours you spent in bed.) 
 
 
5. During the past month, how often have you had 
trouble sleeping because you… 
Not during 
the past 
month 
Less than 
once a 
week 
Once or 
twice a 
week 
Three or more 
times a week 
a. Cannot get to sleep within 30 minutes 
b. Wake up in the middle of the night or early 
morning 
c. Have to get up to use the bathroom 
d. Cannot breathe comfortably 
e. Cough or snore loudly 
f.  Feel too cold 
g. Feel too hot 
h. Have bad dreams 
i.  Have pain 
j.  Other reason(s), please describe: 
6. During the past month, how often have you 
taken medicine to help you sleep (prescribed or 
“over the counter”)? 
7. During the past month, how often have you had 
trouble staying awake while driving, eating meals, 
or engaging in social activity? 

 
No bed 
partner or 
room mate 
Partner/room 
mate in 
other room 
Partner in 
same room 
but 
not same 
bed 
Partner in 
same bed 
 
10. Do you have a bed partner or 
room mate? 
Not during 
the past 
month 
Less than 
once a 
week 
Once or 
twice a week
Three or 
more times a 
week 
I don’t know 
If you have a room mate or bed 
partner, ask him/her how often in the 
past month you have 
had: 
a. Loud snoring 
b. Long pauses between breaths 
while asleep 
c. Legs twitching or jerking while you 
sleep 
d. Episodes of disorientation or 
confusion during sleep 
e. Other restlessness while you 
sleep, please describe: 
 
 
 
No 
problem 
at all 
Only a 
very slight 
problem 
Somewhat 
of a 
problem 
A very big 
problem 
8. During the past month, how much of a problem 
has it been for you to keep up enough enthusiasm 
to get things done? 
Very 
good 
Fairly 
good 
Fairly 
bad 
Very 
bad 
9. During the past month, how would you rate 
your sleep quality overall? 

 
Modified Ask Suicide-Screening Questions (MASQ) 
 
 
 
 

 
NIH Sleep Diary

Protocol Version Date: 09/10/2024 
Page 33 of 38 
 
18. APPENDIX B: SCHEDULE OF EVENTS 
                                    Visit: 
 
Procedure: 
SCREENING2 
Visit 0 
(4 – 21 days 
prior to Day 1) 
BASELINE/WEEK 0 
Visit 1 
(Day 1) 
 
WEEK 1 
Visit 2 
(7 days, +/- 3 
days) 
WEEK 2 
Visit 3 
(7 days, +/- 3 
days) 
WEEK 4 
Visit 4 
(14 days, +/- 
3 days) 
 
WEEK 8 FOLLOW UP 
VISIT 5 
(28 days +/- 3 
days) 
WEEK 12 FOLLOW UP 
VISIT 6 
(28 days, +/- 7 
days) 
Informed Consent 
X 
 
 
 
 
 
 
 
Demographic Information 
X 
 
 
 
 
 
 
 
Relevant Medical History6 
X 
 
 
 
 
 
 
 
Brief Physical Exam 
X 
 
 
 
X 
 
 
 
CO breath test 
X 
X 
X 
X 
X 
 
X 
X 
Height  
X 
 
 
 
 
 
 
 
Weight  
X 
 
 
 
 
 
 
 
Biomarker Assessment-(blood and 
urine) 
 
X 
X 
X 
X 
 
X 
X 
Labs (CMP) 
X 
4 
X 
X 
X 
 
X 
X 
Pregnancy Test (Urine)  
X 
 
 
 
 
 
 
 
Randomization 
X 
 
 
 
 
 
 
 
Administration of Study Drug 
 
X 
X 
X 
 
 
 
 
Review and/or dispense subject Pill 
Diary  
 
X 
X 
X 
X 
 
 
 
Concomitant Medication Review7 
X 
 
 
 
 
 
 
 
Adverse Event Review 
 
X 
X 
X 
X 
 
X 
X 
24-h urine- supplies 
X 
X 
X 
X 
X 
 
X 
 
GT3X+ Wearable device (WD)2 
X 
X 
X 
X 
X 
 
 
 
Questionnaires 
X3 
X 
X 
X 
X 
 
X 
X 
Exit Interview 
 
 
 
 
 
 
 
X 
In-depth Interview5 
(Post-Treatment Interview) 
 
 
 
 
X 
 
 
 
Insert information, as appropriate, if superscripts are used within the table.  Examples provided below. 
Abbreviations; CMP=12 item complete metabolic profile (sodium, potassium, chloride, bicarbonate, blood urea nitrogen, creatinine, glucose, alkaline phosphatase, AST, ALT, total 
bilirubin) 
1. Screening procedures performed per Standard of Care within the screening window can be used even if prior to consent. 
2. GT3X+ wearable device will be provided to participants at the end of Visit 0; the wearable device will be replaced during Visit 1 – 3 by study coordinator and the device will be 
collected during Visit 4. 

Protocol Version Date: 09/10/2024 
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3. MASQ questionnaire only, given at screening 
4. Blood will not need to be redrawn if their baseline visit is within 7 days of their screening labs.  
5. Collected until completed by 25 subjects. 
6. Relevant medical history is defined as any diagnosis of depression.  
7. Concomitant Medications defined as all medications participant is actively taking at time of enrollment.  

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19. APPENDIX C: SUMMARY OF CHANGES 
 
Protocol Version 
Number 
Protocol Version 
Date 
Affected Section(s) 
Summary of Revisions Made 
1.0 
Jun. 8, 2023 
- 
N/A- Initial protocol 
2.0 
Nov. 29, 2023 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Title Page 
 
Abstract 
 
 
Section 2 
 
 
Section 3 
 
 
 
 
 
 
 
 
Section 4 
 
 
Section 5 
 
 
 
Inclusion Criteria 
 
- 
Added Co-I Dr. Frank Orlando 
_____________________________________________________ 
- 
Removed Half-dose treatment arm 
- 
Increased sample size from 75 to 76 
_____________________________________________________ 
- 
Removed Half-dose treatment arm 
- 
Increased sample size from 75 to 76 
_____________________________________________________ 
- 
Removed Arm from Schema visual 
- 
Removed Half-dose treatment arm 
- 
Increased sample size from 75 to 76 
- 
Added UF Consent2Share language 
- 
Added language mentioning UF Springhill Clinic site 
location and Dr. Frank Orlando 
- 
Minor language corrections 
_____________________________________________________ 
- 
Removed Half-dose treatment arm 
- 
Minor language corrections 
_____________________________________________________ 
- 
Added more detailed language for UF Springhill Site 
and UF Consent2Share Program 
- 
Increased sample size from 75 to 76 
 
- 
A) Minor Language Change 
 

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Apr. 15, 2024 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Exclusion Criteria 
 
Section 6 
 
 
Section 9 
 
 
 
Section 10 
 
Appendix B 
 
 
 
 
All Protocol 
Mentions 
 
 
 
 
 
 
 
 
 
 
 
 
 
- 
G) Added language for exclusionary exception 
_____________________________________________________ 
- 
Removed Half-dose treatment arm 
- 
Corrected treatment group labeling language 
_____________________________________________________ 
- 
Removed language mentioning Dr. Firpi  
- 
Added language for Dr. Orlando and Dr. Malaty 
- 
Clarified reporting language 
 
      _____________________________________________________ 
- 
Corrected statistical language for a two-arm trial 
_____________________________________________________ 
- 
Minor change to text symbols ( ) for In-depth Interview 
procedure 
- 
Minor deletion of footnote language for simplification 
- 
Renamed all ASQ Questionnaire (ASQ) language to 
Modified ASQ Questionnaire (MASQ) 

Protocol Version Date: 09/10/2024 
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2.1 
May 20, 2024 
Appendix B: 
Schedule of events 
- 
Removed CBC w/diff from required lab collections 
3.0 
Sep. 10, 2024 
Section 3 
 
 
 
 
 
 
 
 
 
Section 5 
 
 
Section 6 
 
 
Section 7 
 
Section 9 
 
 
Section 15 
 
Appendix A 
 
 
 
Appendix B 
 
- 
Added language to clarify study window for Post-Treatment 
Interview. If missed, will not result in a deviation 
- 
Amended questionnaire list. Minor modification to Pittsburgh 
Sleep Quality Index. Now MPSQI. 
- 
Added NIH Sleep Quality Diary to questionnaire list. Will not 
result in a deviation if missed.  
- 
Added language to clarify Post-Treatment Interview is 
optional. Collection will stop after 25 subjects have 
completed it.  
_____________________________________________________ 
- 
Added new inclusion criteria regarding potential participants 
prior usage of Kava and participation in other Kava trials. 
_____________________________________________________ 
- 
Randomization language amended to more accurately reflect 
current procedures 
_____________________________________________________ 
- 
Language added to define relevant medical history collection. 
_____________________________________________________ 
- 
Language added to clarify the AE reporting window and 
REDCap reporting criteria for Serious and Non-Serious AEs.  
_____________________________________________________ 
- 
Minor formatting change for Appendices 
_____________________________________________________ 
- 
Added entry for MPSQI. It was not previously included in 
Appendix A but was mentioned in prior protocol version. 
- 
Added entry for NIH Sleep Diary 
_____________________________________________________ 
- 
Amended event windows to clarify that visits are scheduled 
from date of prior check-in following Visit 1 (Week 0) 

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- 
Removed collection of concomitant medications at all visits 
except screening. 
- 
Added ‘Pill’ to diary language to avoid confusion with sleep 
diary 
- 
Added footnote #5 to clarify Post-Treatment interview only 
collected until completed by 25 subjects.  
- 
Added footnote #6 to define Relevant Medical History  
collection.  
- 
Added footnote #7 to define concomitant medications 
_____________________________________________________