The Gender-Sex Hormone Interface With Craving & Stress-Related Changes in Smoking
Phase: NA
Conditions: Nicotine Dependence
Sponsor: Kevin Gray, MD

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Version 12.0 (01/12/2016) 
 
 
 
THE GENDER-SEX HORMONE INTERFACE WITH CRAVING & STRESS-RELATED CHANGES IN 
SMOKING 
 
NCT#01576874 
 
Protocol Version 12, IRB-approved January 12, 2016 
 
 

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THE GENDER-SEX HORMONE INTERFACE WITH CRAVING & STRESS-RELATED CHANGES IN 
SMOKING 
 
SPECIFIC AIMS 
Despite considerable advances in treatment development, cigarette smoking remains the leading cause of 
preventable death in the United States, and most smokers engaged in treatment are unsuccessful in quitting.  
The burden of illness is disproportionately borne by female smokers, who are less responsive to cessation 
interventions than males.  The relationships between stress, craving, and smoking behavior are recognized as 
key factors underlying gender differences in nicotine dependence, but must be better understood and 
characterized to yield avenues for interventions addressing this critical health disparity. 
In prior and ongoing SCOR studies, our research team has demonstrated gender and menstrual cycle/sex 
hormone influences on reactivity to laboratory-presented cues.  Building from these laboratory findings, we 
propose taking two important next steps: (1) evaluating the experience of craving in the “real world” natural 
environment of female and male smokers, and (2) examining the impact of a safe and novel pharmacological 
intervention (oxytocin) on stress reactivity in female and male smokers. 
During a 2-week period, participants will use the newly developed and validated Cue Reactivity Ecological 
Momentary Assessment (CREMA) software implemented on a widely available personal digital assistant 
(iPhone) to provide real-time responses to stressful, smoking-related, and neutral picture cues presented multiple 
times daily in their natural environment. Additionally, daily saliva samples will be used to determine sex hormone 
(estradiol, progesterone, and testosterone) levels.  These procedures will provide an unprecedented opportunity 
to prospectively and continuously evaluate dynamic sex hormone influences on cue-responsive craving in the 
“real world” natural environment of smokers. 
Following the two weeks of CREMA data collection, a laboratory session will be conducted to investigate 
responses to acute dosing of oxytocin (versus placebo) in context of controlled evaluation of stress reactivity and 
smoking behavior. Prior to the session, participants will abstain from smoking for 12 hours and provide a salivary 
sample for measurement of stress and sex hormone (cortisol, estradiol, progesterone, and testosterone) levels. 
Participants will receive a double blind intranasal dose of oxytocin or placebo and will then be exposed to the 
Trier Social Stress Test (TSST). Measures collected at multiple time points during the laboratory session will 
include subjective craving, stress, and negative emotion as well as heart rate, blood pressure, skin conductance, 
and cortisol. Immediately following the TSST, participants will complete a smoking resistance task (SRT) in which 
they will receive a monetary reward for every 5-min period they can resist smoking. After completing the SRT, 
participants will be allowed to smoke freely during a one-hour ad libitum smoking period (ASP), with smoking 
topography assessed via a portable device. 
 
Aim 1: Evaluate gender and sex hormone influences on reactivity to stressful and smoking-related cues 
presented, via CREMA, in the natural environment of smokers. 
Hypothesis 1: Female smokers will be more reactive (craving ratings) than male smokers to stressful and 
smoking-related cues presented in the natural environment. 
Hypothesis 2: Among female smokers, estrogen to progesterone ratio will be positively related to reactivity 
(craving ratings) to stressful and smoking-related cues presented in the natural environment. 
 
Aim 2: Evaluate gender, sex hormone, and oxytocin administration influences on stress, craving, and smoking 
behavior response to a laboratory-based stressor task (TSST). 
Hypothesis 1: Female smokers will evidence greater subjective stress, craving, and smoking behavior (e.g., 
shorter latency to smoke during the SRT and greater number of puffs during the ASP), but less 
neuroendocrine reactivity (cortisol), to the TSST than male smokers. 
Hypothesis 2: Oxytocin, relative to placebo, will attenuate subjective stress, craving, and neuroendocrine 
responses to the TSST. 
Hypothesis 3: Among female smokers, estrogen to progesterone ratio will be positively related to craving 
reactivity during the TSST. 
If, as hypothesized, gender, sex hormones, and oxytocin administration influence the relationships between 
stress, craving, and smoking behavior, the findings could substantially address a key gender-related health 
disparity. Such knowledge could also inform the development of gender-specific interventions to enhance female 

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smokers’ response to cessation treatments. Therefore, the knowledge to be gained from the proposed study 
may yield significant public health benefits. 
RESEARCH STRATEGY 
A. SIGNIFICANCE 
Smoking occurs in approximately 21% of the US population, is responsible for an annual mortality rate of 
approximately 438,000 citizens, and has an associated healthcare economic burden of $167 billion . Although 
treatments have improved cessation outcome, the vast majority of individuals making quit attempts relapse within 
5 to 10 days of cessation (Hughes, Keely, & Naud, 2004; Piasecki, 2006). The hypotheses to be examined in 
this proposal may have potentially important implications for the treatment of smoking and will, therefore, target 
the single greatest addiction-related public health problem.  
Gender and Cessation Outcome: Epidemiological data (Giovino, 2002) indicate that smoking rates of both 
men and women have substantially declined from their peak levels in the 1960s but the rate of decline in women 
has been half that observed for men (25% vs. 50% rate reduction, respectively). Additionally, lower rates of 
cessation in women have been reported in studies of self-quitters (Fortmann & Killen, 1994; Husten et al., 1997; 
Ward, Klesges, Zbikowski, Bliss, & Garvey, 1997), smokers in large population-based treatment trials (Bjornson 
et al., 1995; COMMIT, 1995), and smokers in medication and nicotine replacement trials (Davis et al., 1994; 
Killen, Fortmann, Newman, & Varady, 1990; Perkins & Scott, 2008; Scharf & Shiffman, 2004; Wetter, Fiore, et 
al., 1999; Wetter, Kenford, et al., 1999). Thus, several studies of self-quitters and treatment-seekers echo the 
epidemiological data and collectively they suggest that women are less able to quit smoking than men, either 
alone or with the aid of treatment. Since the health and economic costs of smoking are so great, it is vital that 
the tobacco research community focus on the elucidation of factors that contribute to gender differences in 
cessation. Such efforts could inform the development of tailored interventions that strategically address gender-
specific needs of smokers. The focus of this proposal will be to build upon our recent laboratory findings to (1) 
undertake the first prospective evaluation of gender and dynamic sex hormone influences on cue-responsive 
craving in the “real world” environment of smokers (i.e., outside the laboratory), and (2) evaluate the acute effects 
of a gender-relevant pharmacological intervention (oxytocin) targeting stress-induced craving and smoking 
behavior. 
Conceptual Underpinnings of the Proposed Study: Smoking cessation is an important health outcome that 
is complex and multiply determined. Figure 1 depicts a conceptual model of several important causal variables 
that contribute to variation in smoking behavior, including cessation. The figure characterizes gender, and the 
sex hormones that impact gender, as a smoker attribute that provides the larger context for the operation of 
numerous other variables that determine 
cessation outcome but explicitly emphasizes 
the special significance of craving, stress, and 
sex hormones. The figure further suggests 
that 
these 
factors 
can 
operate 
both 
independently (non-overlapping portions of 
each 
Venn 
element) 
and 
collectively 
(overlapping portions of the Venn elements) 
to influence smoking behavior and the results 
of 
quit 
attempts. 
For 
example, 
cues 
associated with smoking can elicit craving to 
smoke independent of the effects of stress; 
however, it is well known that stress can elicit cravings (e.g., see Preliminary Studies, Section C1. below) that 
motivate smoking. Moreover, sex hormones (e.g., variation across the menstrual cycle) influence the experience 
of both stress and craving to smoke (Ferree, Kamat, & Cahill, 2011; Gray et al., 2010).  The unfilled space in the 
gender sphere acknowledges that numerous other variables influence cessation outcome (e.g., variation in 
responsiveness to social support, Murray, et al., 1995; personality and demographic factors, Gilbert, 1995, etc.), 
while at the same time clearly establishing the importance of craving, stress, and gender/sex hormones. The 
proposed study is specifically designed to examine associations among these potentially important contributory 
causes of variation in cessation outcome.   
Interface between Craving, Stress, and Smoking, and the Importance of “Real World” Methodology: Recent 
research has led to a richer conceptualization of craving as a multidimensional response that is elicited by a 
variety of stimuli and or experiences; as noted above, craving is often elicited by stimuli (sight and smell of 
cigarettes) that have a prior history of being paired with nicotine ingestion. Craving is also elicited by stress-

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inducing stimuli and/or situations, as has been demonstrated in several studies (Buchmann et al., 2010; Maude-
Griffin & Tiffany, 1996; R. S. Niaura, Shadel, Britt, & Abrams, 2002; Payne, Schare, Levis, & Colletti, 1991; 
Perkins & Grobe, 1992; Tiffany & Drobes, 1990).  To date, however, nearly all cue reactivity assessment has 
occurred in the laboratory, a “sterile” setting that, while providing experimental control, lacks the rich context of 
smokers’ day-to-day natural environment.  If cue-elicited craving has a meaningful relationship to “real world” 
smoking behaviors and cessation outcomes, its investigation must be translated to that same “real world.”  We 
thus propose using novel methodology (Gass, Wray, Hawk, Mahoney, & Tiffany, 2011; Warthen & Tiffany, 
2009a; Wray, Godleski, & Tiffany, in press) to undertake the first investigation of gender and sex hormone 
influences on cue-elicited craving in the natural environment of smokers. 
Rigorous Stress-Reactive Smoking Laboratory Paradigm: While translation of gender/sex hormone/craving 
investigation to the natural environment of smokers is a key element of the proposal, we acknowledge the 
laboratory as the ideal setting for evaluation of acute pharmacological effects on reactivity. Of special relevance 
to the proposed work, a recent study by McKee and colleagues (McKee et al., 2011) employed a laboratory-
based, personalized (imagery) stressor task to examine, in overnight deprived smokers, the effects of stress on 
(a) ability to resist smoking in exchange for monetary reward, and (b) subsequent smoking behavior as measured 
with a smoking topography device. They observed that stress decreased resistance to smoke, increased 
smoking intensity (e.g., number of puffs) and increased satisfaction and reward from smoking. Relatedly, our 
ongoing SCOR protocol has offered some initial insight into the association between sex hormone levels and (a) 
craving during a smoking cue reactivity assessment, and (b) topographical aspects of smoking behavior obtained 
during a 1-hour ad libitum smoking period (see Preliminary Studies, Section C1. below). These findings are 
consistent with a large body of research indicating that smokers perceive stress to be a major contributor to 
relapse episodes (Baer, Kamarck, Lichtenstein, & Ransom, 1989; Baer & Lichtenstein, 1988; Brandon, 1994; 
Brandon & Baker, 1991; Piper et al., 2004) and that quit rates are lower among smokers experiencing serious 
psychological distress (Hagman, Delnevo, Hrywna, & Williams, 2008; Sung, Prochaska, Ong, Shi, & Max, 2011). 
Collectively, these study findings suggest that stress may reduce resistance to smoking, potentially via 
augmented craving, and increase smoking behavior.  The proposed study will employ a strategy similar to McKee 
et al but will employ the Trier Social Stressor Task (TSST) to provoke a stress response in overnight deprived 
smokers, providing the unprecedented opportunity to examine gender, sex hormone, and acute pharmacological 
effects on post-stressor measures of smoking behavior (i.e., resistance to smoke and smoking topography). 
Evaluation of a Novel Candidate Pharmacotherapy: Oxytocin, a neuropeptide synthesized in the 
hypothalamus, plays a critical role in mating, childbirth, and lactation (Ludwig & Leng, 2006) and appears to have 
pro-social and anxiolytic effects (Francis, Young, Meaney, & Insel, 2002; Fries, Ziegler, Kurian, Jacoris, & Pollak, 
2005; Williams, Insel, Harbaugh, & Carter, 1994; Witt, Winslow, & Insel, 1992).  Recent studies indicate that (a) 
oxytocin may be dysregulated in chronic substance dependence (Sivukhina, Dolzhikov, Morozov Iu, Jirikowski, 
& Grinevich, 2006), and (b) acute intranasal administration of oxytocin reduces subjective and neuroendocrine 
stress response (de Oliveira, Zuardi, Graeff, Queiroz, & Crippa, 2011; Heinrichs, Baumgartner, Kirschbaum, & 
Ehlert, 2003; Kosfeld, Heinrichs, Zak, Fischbacher, & Fehr, 2005), suggesting that administration of exogenous 
oxytocin may be a promising candidate intervention targeting stress-induced drug craving and drug self-
administration. Pilot data obtained at our SCOR site (see Preliminary Studies, Section C1. below) revealed that 
cannabis dependent participants pre-treated with intranasal oxytocin exhibited reduced anxiety and cannabis 
craving in response to a laboratory stressor task (TSST), compared with those pre-treated with placebo. These 
findings, especially in light of oxytocin’s well-established safety and tolerability, suggest that oxytocin is an ideal 
candidate for evaluation as an intervention targeting stress-induced craving and smoking behavior. 
B. INNOVATION 
One of the major innovative features of this protocol is the measurement approach that will be adopted. Until 
relatively recently, nearly all craving and cue reactivity data were collected in laboratory settings rather than in 
the “day-to-day” natural environments of smokers. However, Tiffany (Co-I on this application) and colleagues 
(Gass, et al., 2011; Warthen & Tiffany, 2009a; Wray, et al., in press) have developed a portable methodology, 
termed cue reactivity ecological momentary assessment or CREMA, which permits real-time cue reactivity 
assessment in the natural environment of smokers. This methodology, which was based on the ecological 
momentary assessment (EMA) procedures originally developed by Shiffman and colleagues (Shiffman et al., 
2002; Shiffman et al., 1997; Shiffman, Paty, Gnys, Kassel, & Hickcox, 1996; Shiffman, Paty, Gwaltney, & Dang, 
2004; Stone & Shiffman, 1992, 1994), utilizes a handheld personal digital assistant technology (PDA; Tungsten 
E2 by Palm, Inc.) to present pictures of smoking-related cues and smoking-unrelated (neutral) control cues to 
smokers at varied times during the day (see Preliminary Studies, Section C1. below for summary of published 

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findings). The CREMA technology developed by the co-investigator on this application (Stephen Tiffany, Ph.D.) 
is an effective methodology for assessing subjective cue-elicited craving and mood responses, across extended 
periods of time, in the natural environment of smokers. Accordingly, we propose to implement a refined version 
of the CREMA assessment methodology on the Apple iPhone platform and examine the impact of gender and 
sex hormones on craving and cue reactivity assessed in the natural environment. 
A complementary longitudinal assessment strategy that will be employed in the present study is the collection 
of salivary samples for the purpose of determining daily levels of sex hormones in all participants. This “high-
resolution” approach to characterizing reproductive hormone fluctuations is relatively rare in addictions research 
(Fox, Hong, Paliwal, Morgan, & Sinha, 2008; Fox, Wilker, Kreek, & Sinha, 2006) but is fairly commonly employed 
in other research domains (Chapman, McIntyre, Lipson, & Ellison, 2009; Edler, Lipson, & Keel, 2007; Gann, 
Giovanazzi, Van Horn, Branning, & Chatterton, 2001; Klump, Keel, Culbert, & Edler, 2008). The proposed study 
contains a plan to, for the first time, measure daily hormone levels and evaluate their relationship with (a) 
reactivity to stressful and smoking-related cues presented in the natural environment of smokers via CREMA 
procedures, and (b) stress-induced changes in smoking behavior assessed in a laboratory environment.  
We additionally propose evaluating the acute effects of oxytocin, a safe and potentially promising 
pharmacotherapy, on stress-induced craving and smoking behavior in women and men within an innovative, 
rigorous laboratory paradigm. While oxytocin has been the subject of increasing interest in regard to social 
behaviors and anxiety, its investigation in the field of addictions, and specifically in nicotine dependence, is novel. 
The overall design of the study is especially novel in that it will integrate sophisticated laboratory procedures with 
naturalistic and/or longitudinal methodologies to exhaustively examine gender and sex hormone influences on 
smoking behaviors.   
C. APPROACH 
C1. Preliminary Studies 
Relevant Gender Differences Experience. In one of our previous SCOR studies (Saladin et al., in press) we 
examined the effects of gender on craving and cue reactivity. We recruited female (n=37) and male (n=53) 
nicotine dependent smokers to participate in a multi-session laboratory study of craving and cue reactivity to 
smoking and stress/negative affect cues. The smoking cues consisted of a package of the participant’s preferred 
brand of cigarettes, which (s)he held and manipulated for 90 sec. as instructed by research staff. The 
stressful/negative affect cues consisted of a detailed description of a recent life event that the participant 
perceived as emotionally negative and stressful. Neutral control cues for the smoking cues consisted of a similar 
guided manipulation of a pack of pencils and an eraser while a script of a neutral or relaxing event that the 
participant had recently experienced served as a control for the stressful/negative affect script. Following each 
cue presentation, participants provided subjective ratings of stress, craving, arousal (calm vs. aroused), valence 
(pleasant vs. unpleasant; lower ratings indicate more unpleasant) and dominance (feeling in control vs. feeling 
out-of-control/submissive; lower ratings indicate feeling more out-of-control/submissive). In addition to subjective 
measures, heart rate (HR) and skin conductance (SC) 
measures of physiological arousal were assessed at 
baseline and during each cue exposure. ANCOVAs 
were performed to assess gender differences in cue 
reactivity; covariates in the models were responses to 
neutral cues, FTND score (measure of nicotine 
dependence level) and order of cue presentation. 
Results of analyses performed on smoking cue data 
indicated that although women trended toward having 
greater stress, craving, arousal, and lower valence and 
dominance ratings than men, none of the differences 
reached significance (e.g., arousal difference, p = .09).  
Analyses of the HR/SC data indicated that (a) women 
trended towards greater heart rate than men (p = .05) 
but this effect was not cue specific (i.e., did not vary 
across smoking vs. neutral cue type), and (b) SC level 
was higher on smoking vs. neutral cue trials (p < .01) but this effect did not vary by gender. Figure 2 shows the 
stress, craving, arousal, valence and dominance ratings in response to the stressful/negative affect script. The 
figure clearly shows that women, relative to men, evidence greater stress, craving, arousal and negative emotion 
Stress
Craving
Arousal
Valence
Dominance
1
2
3
4
5
6
7
8
Rating Type
Mean  Rating Magnitude
*
*
*
*
Figure 2
Women
Men
* = p < .05

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(lower valence ratings) in response to the script cues. Overall, the findings of this and eight other studies 
(Colamussi, Bovbjerg, & Erblich, 2007; Field & Duka, 2004; Heishman, Lee, Taylor, & Singleton, 2010; Knott, 
Cosgrove, et al., 2008; Knott, Naccache, et al., 2008; R. Niaura et al., 1998; Rohsenow et al., 2007; Tong, 
Bovbjerg, & Erblich, 2007) reporting on gender differences in cue reactivity suggest two general conclusions: (1) 
the two studies examining gender differences in stress/negative affect cue reactivity have clearly demonstrated 
that women vs. men experience greater craving to smoke, higher arousal/stress and greater negative emotion 
in response to stress/negative affect cues, and (2) five of eight studies examining gender differences in reactivity 
to smoking cues found women to be more craving responsive. Thus, the available evidence appears to suggest 
that women tend to be more responsive to both cue types, albeit less definitively in the case of smoking cues. 
Of note, laboratory-measured neuroendocrine (e.g., cortisol) reactivity may not follow the same gender pattern, 
as prior studies suggest that men exhibit more cortisol reactivity to psychological stressors than women (Back 
et al., 2008; Kirschbaum, Kudielka, Gaab, Schommer, & Hellhammer, 1999; Kirschbaum, Wust, & Hellhammer, 
1992; Kudielka & Kirschbaum, 2005), a finding that may be accentuated among smokers in light of gender-
imbalanced dampening of neuroendocrine response over chronic nicotine administration (Back et al., 2008).  
 Relevant Experience Examining Menstrual Cycle/Ovarian Hormone Effects on Craving/Smoking Behavior. 
Our initial efforts to understand the role of sex hormones in smoking focused on menstrual cycle phase effects 
on smoking-related craving and cue reactivity (Gray, et al., 2010). In this study, female smokers (n=37) received 
a smoking cue reactivity assessment during each of four biologically verified phases of the menstrual cycle: 
early- and mid-follicular and mid- and late-luteal. Stimuli presented during the cue reactivity assessments were 
in vivo smoking cues, which consisted of manual handling of the participant’s preferred brand of cigarettes, and 
scripted stressful/negative affect cues, which consisted of an personalized imagery script of a stressful event in 
the participants recent past. Control cues for the smoking and stress/negative affect cues consisted of the 
handling of pencils & eraser and a relaxing imagery script, respectively. Results indicated significant variation 
across the cycle, with craving to smoking cues elevated in the follicular phases, relative to the luteal phases (p 
= .02). Heart rate reactivity to stressful/negative affect cues (p = .01) and skin conductance reactivity to smoking 
cues (p = .05) varied across cycle phases as well, with maximum reactivity occurring during the mid-follicular 
phase. These findings, taken together, demonstrated elevated reactivity during at least part of the follicular 
phase, but it remained unclear what underlying ovarian hormone fluctuations might be contributory. While other 
studies (Sofuoglu, Babb, & Hatsukami, 2001; Sofuoglu, Mouratidis, & Mooney, 2011) have suggested that 
progesterone, which is present in higher levels during the luteal phase relative to the follicular phase, may have 
a protective effect against craving, it remained unclear whether progesterone effects may be static versus 
dynamic (i.e., related to absolute level at a given time point versus change in level over time), or whether estradiol 
might also contribute.      
A goal of our ongoing SCOR study is to more directly investigate the relationship between ovarian hormones 
and smoking behavior.  Within this study, we examined the predictive relationship between static and dynamic 
plasma levels of estradiol and progesterone and (a) craving elicited in a human laboratory cue reactivity 
procedure, and (b) smoking behavior during a subsequent 1-hour ad libitum smoking session. Briefly, 93 female 
smokers received an initial assessment to determine study eligibility, nicotine dependence severity, etc. 
Approximately one week later, participants were administered a standardized cue reactivity assessment where 
the Questionnaire of Smoking Urges–Brief (QSU-B) was used to measure craving prior to and after exposure to 
smoking-related cues (i.e., preferred brand of cigarette & lighter). An ad libitum smoking session followed, with 
measurement of smoking behavior via a topography device.  Estradiol and progesterone levels were derived 
from plasma samples collected at the time of the initial assessment (T1) and the laboratory cue reactivity 
assessment (T2). The primary predictor variables were absolute levels of estradiol and progesterone at T2, % 
change in estradiol and progesterone between T2 and T1; primary craving reactivity outcomes were QSU-B 
factor and total scores (difference score = postcue - precue craving) and primary ad libitum smoking outcomes 
were number of puffs and weight of cigarettes smoked.   
Cue reactivity analyses indicated that the ratio of estradiol to progesterone correlated positively (p < .05) with 
QSU craving.  While not significant in magnitude within the preliminary sample, the direction of association was 
positive for estradiol (T2 level and % change between T1 and T2) and negative for progesterone measures (T2 
level and % change between T1 and T2).  Ad libitum smoking analyses revealed a similar pattern of findings.  
While directional trends existed in static and dynamic hormone associations with smoking variables, only the 
ratio of progesterone to estradiol significantly predicted number of puffs (p < .01) and weight of cigarettes (p < 
.05) smoked.  These findings are among the first to suggest that the smoking behavior of women may be 

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influenced by the relationship between estradiol and progesterone rather than by the effects of progesterone 
alone, as suggested by at least two previous laboratory studies (Sofuoglu, et al., 2001; Sofuoglu, et al., 2011). 
Absent from these and other human investigations of sex hormone effects on craving and smoking behavior 
is the role of testosterone in males. Testosterone levels vary temporally in men, and these variations are 
associated with behavioral changes (Kempenaers, Peters, & Foerster, 2008; Rowe et al., 1974; Stanton, 
Mullette-Gillman, & Huettel, 2011). Acute administration of testosterone decreases cocaine self-administration 
in rhesus monkeys, a parallel to the acute effects of progesterone administration (Mello, Knudson, Kelly, Fivel, 
& Mendelson, 2011). In the context of research involving gender and sex hormone effects on craving and 
smoking behavior, testosterone thus appears to be an important, albeit exploratory, variable for investigation. 
Since daily testosterone levels will be assessed in the male participants of this study, an opportunity will provided 
to explore, for the first time, the association between testosterone levels and (a) cue-elicited craving measured 
daily for two weeks in the natural environment, and (b) stress reactivity to the TSST and subsequent smoking 
behavior (as measured during the smoking resistance task and the ad libitum smoking period).  
Relevant CREMA Experience. As noted above, Dr. Stephen Tiffany (Co-Investigator) and colleagues have 
developed a PDA-based technology (Palm Tungsten E2, Palm Inc.) called cue reactivity ecological momentary 
assessment or CREMA, which they have successfully used to administer experimental cue reactivity sessions 
in the natural settings of smokers and to gather real-time measurement of craving, mood, smoking behavior, 
temporal data and contextual variables. In the first of two published studies (Warthen & Tiffany, 2009a) using 
this technology, 43 non-treatment seeking, heavy smokers were trained to use PDAs that administered 4 cue 
reactivity (CR) sessions each day for 8 days. The daily CR session occurred randomly over the course of a 12-
hour period (determined by the participant at the outset of the study) and consisted of one cue type from four 
categories: (1) smoking picture, (2) smoking imagery script, (3) neutral picture, and (4) neutral imagery script. 
Participants also provided data on the timing of their smoking during the course of the day. Additionally, 
laboratory-based CR sessions were performed with the PDA prior to and following the 8-day CREMA 
assessment period. Results indicated that the smoking pictures and smoking imagery cues elicited significantly 
greater craving, negative mood and lower positive mood than either of the corresponding neutral cues in both 
the CREMA sessions and the laboratory-based CR assessments. A second study by Tiffany and colleagues 
(Wray, et al., in press), which employed a 
similar 8-day CREMA assessment design, 
found smoking pictures to be more effective 
than in vivo smoking cues (i.e., handling a real 
cigarette) at eliciting cue specific craving and 
negative emotion. This observation held 
regardless of whether the picture and in vivo 
cues were presented in the participant’s 
natural environment or in a laboratory setting. 
Finally, Figure 3 depicts smoking vs. neutral 
picture cue-elicited craving (error bars are 
SEM) from 60 treatment-seeking smokers who 
participated in a third study involving a 5-week 
CREMA assessment period that preceded a 
target quit date. Since one of the goals of this 
study was to determine whether varenicline 
dampened cue-elicited craving, half of the participants received varenicline during weeks 2, 3 & 4 and the other 
half received placebo (double-blinded). The figure shows that CREMA procedures can be used to assess cue-
elicited craving over an extended period of time (effects sizes- partial eta2 - ranged from .62 at week 1 to .19 at 
week 5). Collectively, these three CREMA studies indicate that (1) smoking picture cues presented on a PDA 
are equal to, or better than, both imagery and in vivo cues at eliciting craving and negative mood, (2) these 
differential cue reactivity effects are as (if not more) robust when measured in the natural environment vs. 
laboratory setting, (3) CREMA procedures can be used over extended periods of time to reliably measure cue 
specific craving, mood, smoking behavior, temporal data and contextual variables. Accordingly, the proposed 
study will employ an enhanced version of CREMA methodology (implemented on the popular Apple 
iPhone platform) to measure cue-elicited craving, mood and other responses to stressful, smoking-
related, and neutral picture cues. These data, together with the sex hormone levels measured daily over the 
same two-week period will permit the assessment of the association between estradiol, progesterone and 
Week 1
Week 2
Week 3
Week 4
Week 5
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
Weeks of CREMA Assessment
Mean  Post-Cue 
Craving Magnitude
Smoking
Neutral
Figure 3
Cue-Specific Craving Effect: 
F = 44.6, p < .001

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testosterone and cue-elicited responses to smoking and neutral picture cues presented during the same two-
week period.  
Relevant Oxytocin Experience. Members of MUSC’s SCOR 
research team (McRae, Brady) recently completed a pilot study 
examining the effects of intranasal oxytocin vs. placebo on the 
subjective craving and anxiety responses of marijuana-dependent 
individuals before and after administration of the Trier Social 
Stressor Task (TSST). Figure 4 depicts the mean craving 
responses of the oxytocin vs. placebo treated groups prior to 
receiving 
oxytocin/placebo 
(Pre-Med 
BL), 
after 
receiving 
oxytocin/placebo but prior to the TSST (Post-Med BL) and 
immediately following the TSST (Post-TSST). The data indicate 
that while the groups exhibited similar levels of craving prior to 
medication administration, oxytocin appears to have a dampening 
effect on craving both before (p = .06) and after (p = .03) the TSST 
is administered. Parallel finding were observed for subjective 
anxiety (not shown). Thus, these preliminary findings suggest that 
oxytocin may have potential as therapeutic adjunct for managing 
both basal and stress-elicited craving and anxiety in substance 
dependent individuals. The proposed project will employ a similar research strategy with nicotine dependent 
smoker to examine whether oxytocin (vs. placebo) (a) reduces stress and craving reactivity to the TSST, and (b) 
enhances smoking resistance and attenuates smoking behavior/topography. Since the sex hormone levels of a 
substantial number of male and female smokers will be quantified in the two-week period preceding the 
laboratory stress procedures, the proposed research design will permit an exploratory analysis of the association 
between sex hormone levels and oxytocin’s impact on laboratory measures of stress reactivity/smoking behavior 
and also the interaction between medication condition and gender. 
C2. Research Team 
Dr. Saladin (PI) and Dr. Gray (Lead Co-I), have a long history of collaboration inclusive of their roles on the 
ongoing SCOR nicotine component study.  They possess complementary skills critical to the completion of the 
proposed study, and have assembled and trained a research staff adept with the skills necessary for day-to-day 
study management.  Dr. Saladin is a clinical psychologist with expertise in craving, cue reactivity, and the 
interface between stress and substance use disorders.  Dr. Gray is a psychiatrist with expertise in assessment 
and clinical management of nicotine dependence.  Dr. Tiffany, Co-I, is an internationally recognized addictions 
researcher with special interest in craving and cue reactivity in 
nicotine dependent smokers. He has conducted numerous NIH-
funded laboratory studies with smokers and has published 
extensively on the relationship between craving, stress and 
negative emotion. His most recent work has examined smoking 
cue reactivity in the natural environment of smokers using 
picture cues administered via a hand-held PDA (referred to as 
cue reactivity ecological momentary assessment or CREMA), a 
critical component of the proposed study. 
C3. Design and Methods 
C3a. Overview. 
The proposed project incorporates naturalistic and 
laboratory procedures to comprehensively evaluate gender and 
reproductive hormone effects on stress reactivity and smoking 
behavior (see Figure 5). Cue reactivity ecological momentary 
assessment (CREMA), involving the assessment of reactivity to 
stressful and smoking-related cues, will be conducted four 
times daily for two-weeks in the natural environment of female 
and male nicotine dependent smokers, while daily salivary 
sampling will be used to track changes in reproductive 
hormones (estradiol and progesterone in females and 
Pre-Med BL
Post-Med BL
Post-TSST
20
30
40
50
60
70
80
Time Point
Mean Craving Magnitude
Oxytocin  (n=8)
Placebo (n=8) 
Figure 4
TSST
Day -7 
Assessment 
Informed Consent, 
Inclusion/Exclusion, 
Baseline Measures 
Day 0 
Training 
CREMA 
Procedures and 
Saliva Assays 
Days 1-14 
CREMA and Daily Saliva Sampling 
Four CREMA Sessions per Day 
Saliva Sample Collection Every Morning 
(Estradiol, Progesterone, Testosterone) 
Figure 5 
Day 15 
Laboratory Session 
Oxytocin or Placebo Administration 
Trier Social Stress Task 
Smoking Resistance Task 
Ad Libitum Smoking with Topography 

9 
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testosterone in males).  On the last day of the second week, following a 12-hour period of smoking abstinence, 
a laboratory session will be conducted. At the beginning of this session, participants will receive nasal 
administration of either oxytocin (OXY) or placebo (PBO) prior to the administration of the Trier Social Stress 
Test (TSST). Random assignment and double-blinding procedures will be employed to ensure that (a) each 
participant will have an equal probability of receiving OXY or PBO, (b) approximately half of the female and male 
smokers will receive OXY while the remaining half will receive PBO, and (c) neither the participant nor the 
research staff will know whether the participant received OXY or PBO. Established self-report, physiological, and 
laboratory measures of stress/cue reactivity will be administered at regular intervals prior to, during and following 
the TSST. To assess the acute effects of stress on smoking behavior, the TSST will be followed by a smoking 
resistance task (SRT) and an ad libitum smoking period (ASP) using smoking topography assessment 
technology. 
We considered several potential alternative designs, including options that would involve only naturalistic or 
laboratory assessments/procedures (rather than both). The naturalistic (CREMA) approach holds appeal in 
terms of innovation, and allows for an analytically strategic pairing of cue reactivity and smoking behavior 
measurement (multiple sessions daily) with serial reproductive hormone measurement over the course of two 
weeks. The laboratory approach provides assessment of reactivity in a highly structured and controlled 
environment, and allows for detailed assessment of the acute effects of a standardized stressor on smoking 
behavior, as assessed with the SRT and ASP. It also permits the assessment of the effects of a very novel 
pharmacological agent, oxytocin, on stress reactivity and smoking behavior. Therefore, we concluded that the 
proposed design offers a mutually complementary integration of naturalistic and laboratory-based methodologies 
that balance internal and external validity and maximize the opportunity to comprehensively assess the role of 
gender and sex hormones in stress induced alterations in smoking behavior.  
C3b. Participants and Recruitment. 
 
A total of 250 smokers , between the ages of 18-45, will be recruited over a 51-month period. The 
oversampling of female participants was necessary to achieve adequate power to test hypotheses involving 
ovarian hormone measures. The sample size determination was based on statistical power necessary to test 
primary hypotheses as outlined in the Sample Size Determination, Section C3i, below.  
 
Participants will be recruited from the general community through media advertising (radio, print, online and 
television). Advertisements will target smokers interested in participating in a study examining the relationship 
between stress and smoking. This media-based recruitment strategy has generated large numbers of 
participants for both cessation and non-cessation studies. To illustrate, we have an ongoing cessation study for 
women smokers that attracted 400 screening calls and netted 46 study enrollees over a 12-month recruitment 
period. Respondent-Driven Sampling (RDS) will also be used to enhance recruitment of the sample. The RDS 
sampling methodology is based on recruiting the eligible friends and acquaintances of each participant so that 
the sample “snowballs”. Each eligible participant who is randomized into the study, and agrees to take part in 
this recruitment assistance, will be given business cards to pass on to other potential participants. The 
business cards will have a unique code linked to the person who passes them out. A referral will be instructed 
to call the site offices for screening and, if eligible, an appointment for further evaluation. If a referral completes 
the screening process and is eligible for the study, the participant who referred the person can redeem the 
business card for $20. 
 
Since the proposed study targets both female and male smokers who are not currently interested in 
quitting, we anticipate successfully recruiting at least 2-3 female and 1-2 male smokers per month using our 
aggressive recruitment strategies. This rate of recruitment will allow us to achieve our target sample over the 
51-month recruitment period. Inclusion/exclusion criteria for the study are located in the Protection of Human 
Subjects section of this application. 
C3c. Intake and Comprehensive Assessment. 
Individuals interested in the study will receive a brief telephone screening to determine if they may be eligible 
to participate. They will then be scheduled for an initial assessment session, consisting of an informed consent 
procedure, followed by completion of medical history, physical exam, self-report questionnaires, and semi-
structured interviews to determine study eligibility. If volunteers complete the informed consent process and are 
eligible for participation, they will be enrolled in the study.  A comprehensive battery of instruments will be 
administered to characterize participants’ smoking, stressor exposure history (past and current), and general 
psychiatric functioning (see Instruments/Measures, Section C3g.).  The research team will use several methods 
of contact to keep in touch with participants. We will ask them to provide us with phone numbers, e-mail 

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addresses, current home and work addresses, and contact information of family and friends who may know how 
best to reach them.  We will also have a Facebook account that we may use to contact participants. The research 
team will only use private messages to contact participants through Facebook 
We considered incorporating luteinizing hormone home testing kits to randomize female participants to start 
study procedures at the outset of the follicular or luteal menstrual cycle phase, but opted not to for multiple 
reasons. First, we noted in our initial SCOR study that the associated lag in initiation of study procedures for 
some women was associated with relatively high dropout rates.  Additionally, the proposed study will enroll both 
men and women and we wanted to avoid using any menstrual phasing procedures that would result in 
substantially different treatment of male and female participants (i.e., long delays before the occurrence of study 
procedures for some females but no delays for other females and all males). Second, we noted in our subsequent 
SCOR study that enrolling a similarly sized sample of women resulted in an even distribution of enrollees across 
the menstrual cycle (while also resulting in improved participant retention rates).  We also felt it important to 
progress from a “follicular versus luteal” phase approach to a continuous measurement approach involving the 
direct assessment of hormone levels. Therefore, we elected to use a participant enrollment approach that will 
allow women to enroll at any time/stage of the menstrual cycle. 
C3d. Training Procedures. 
Enrolled participants will return for a training visit, during which they will gain mastery of saliva sample 
collection and storage, personal digital assistant (PDA; iPhone) operation, and CREMA procedures. 
C3e. Natural Environment Procedures. 
CREMA Assessment. Participants will carry a PDA for two  weeks (Days 1-14). They will be instructed to 
keep the PDA with them at all times. Auditory alarms will alert participants to complete four, randomly scheduled 
cue-reactivity/CREMA sessions per day (session duration = 3-4 min.). Alarms will be distributed over a 12-hour 
period, divided into four, 3-hr blocks with a minimum time of 30 minutes between alarms/CREMA sessions. Each 
CREMA session will contain two trials and each trial will consist of one picture cue presentation. There will be 
three types of picture cues that differ based on content: stressful (e.g., stress-inducing images from the 
standardized International Affective Picture System [IAPS; Libkuman et al., 2007; Rehme et al., 2009]), smoking 
(e.g., lit cigarettes, people smoking, etc.) and neutral (e.g., pencils, scissors, etc.). Thus, each of the four daily 
CREMA sessions will contain two picture cues from one or a combination of these three categories.  
At the start of each CREMA session, participants will be asked to finish their cigarette if they were smoking, 
then provide craving and mood ratings, and answer questions about distractibility, etc. (see Section C3g. 
Instruments/Measures). Next, a photograph will be presented and the participant will be instructed to look at it 
carefully. Each picture cue will appear only once during the study. An alarm will sound at the end of each trial, 
after which participants will complete a post-cue assessment consisting of the Craving Questionnaire, mood 
items, and ratings of how carefully they looked at the photograph and their distraction level during each trial. 
CREMA sessions will present the pictures for 10 seconds.  
Participants will be prompted for four CREMA sessions per day on Days 1-14, and will thus complete a 
maximum of 56 CREMA sessions. To encourage CREMA session completion, participants will be compensated 
$1.25 for each completed session (see Participant Compensation, Section C3h). Previous studies employing 
this incentive strategy have reported 90% CREMA completion rates (Gass, et al., 2011; Warthen & Tiffany, 
2009a; Wray, et al., in press). 
Saliva Sample Collection.  Participants will, via established procedures reviewed during the training visit, 
collect saliva samples a half hour after awakening. Samples will be dispensed into containers supplied by study 
staff, and stored in participants’ home freezers until bringing the samples to a subsequent study visit.  The 
laboratory will analyze samples for levels of estradiol & progesterone (females only) and testosterone (males 
only).  These daily home collection and storage procedures have been used in numerous previous studies with 
excellent participant adherence and sample quality (Edler, et al., 2007; Klump, et al., 2008). 
C3f. Laboratory Procedures. 
An overview of the laboratory session procedures is presented in the Laboratory Procedure Timeline table. 
Participants will receive the following instructions to prepare for their laboratory session: they are to 1) abstain 
from smoking for 12 hours; generally, this will mean not smoking overnight before the laboratory session, 2) 
abstain from alcohol/other drug use for a minimum of two days prior to the laboratory session, 3) perform saliva 
collection the morning of the laboratory session and bring it, as well as the samples collected during the previous 
week, to the appointment, and 4) arrive at MUSC’s Clinical Neurosciences Division office between 9:00 and 9:30 

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AM the day of their scheduled laboratory session. Upon arrival at the office, participants will provide research 
staff with the saliva samples they collected over the previous 8 days; in the event that a participant fails to collect 
a saliva sample the morning of the laboratory session, (s)he will be requested by research staff to provide a 
sample on site. Smoking abstinence will be confirmed via carbon monoxide assessment and abstinence from 
alcohol/other drug use will be assessed via breathalyzer and urine drug screen (UDS). Participants who fail any 
of the abstinence assessments will have their laboratory session re-scheduled at the earliest possible date. 
Individuals who must reschedule their laboratory session will be asked to continue to collect saliva samples daily 
upon awakening until the day of their laboratory session. Next, sensors for the measurement of heart rate and 
skin conductance will be affixed to the participant and a blood pressure cuff fastened to the non-dominant arm. 
Participants will complete baseline assessments (salivary cortisol, craving, stress, mood, etc.) and then receive 
a lunch snack. Participants will sit quietly for approximately 20-30 minutes after finishing their snack and then 
will receive nasal administration of either oxytocin or placebo (described in more detail below) at 12:00 noon.  
Approximately 30 minutes following medication administration, a second set of baseline measures will be 
obtained, after which the participant will sit comfortably until the Trier Social Stress Test/TSST (Kirschbaum, 
Pirke, & Hellhammer, 1993) begins.   
The TSST procedure is widely recognized as the gold standard for evoking stress response in the laboratory 
(Dickerson & Kemeny, 2004). It begins when the participant is told that (s)he will soon have to perform both a 
speech and arithmetic task in front of an audience. They are told that the topic of the speech is why (s)he should 
be hired for a particular job (the participant’s “dream job”). The participant will deliver the speech as though 
speaking to a group of hiring managers. The experimenter then tells the participant that (s)he has 5 min to 
prepare the speech, and starts the countdown clock (placed in view of the participant). The experimenter leaves 
the room to allow the participant to prepare. Five minutes later, three individuals unfamiliar to the participant (the 
audience) enter the room and are seated; the participant is instructed by one audience member (the 
spokesperson) to stand and begin his/her prepared speech (without notes). The speech is delivered for 5 min; if 
the participant pauses, (s)he is instructed by the spokesperson to continue.  At the end of the speech task, the 
participant is instructed to serially subtract 13 from 1,022 as quickly and accurately as possible.  The mental 
math recitation continues for 5 min, and at its conclusion, the spokesperson instructs the participant to stop and 
be seated, and the audience leaves the room.  The total time for the TSST procedure is approximately 15 min. 
Laboratory Procedure Timeline 
TIME 
PROCEDURE(S) 
MEASUREMENT(S) 
10-10:55 AM 
General Assessment & Preparation 
CO Assessment; Breathalyzer; UDS; Saliva 
collection (if not done at home); NWSC; STAI, 
Mood Form; DDT.  
11:00-11:30 AM 
Placement of HR & SC sensors & BP cuff; 
Baseline 1 Measurements; Snack. 
CQ; CREMA Mood & Stress Assessment; 
NWSC; HR, SC & BP; Cortisol. 
12:00 Noon 
Intranasal Administration of Oxytocin or 
Placebo 
 
12:30 PM 
Baseline 2 Measurements 
CQ; CREMA Mood & Stress Assessment; 
NWSC; HR, SC & BP; Cortisol 
12:45-1:00 PM 
Trier Social Stressor Task (TSST) 
 
1:00 PM 
Immediate post-TSST assessment;  
SRT begins.  
CQ; CREMA Mood & Stress Assessment; 
NWSC; HR, SC & BP; Cortisol; DDT 
1:20 PM 
20-minute, post-TSST assessment 
 
*Cortisol & subjective 
stress (verbal report) 
will be assessed 20, 40 
& 60 min. post-TSST. 
*CQ, CREMA Mood & 
Stress Assessment, 
NWSC, HR, SC & BP 
will be assessed when 
each participant ends 
SRT and during ASP 
at 30 and 60 min. 
1:40 PM 
40-minute, post-TSST assessment 
1:50 PM 
Maximum duration of SRT reached. 
Latest time that ASP begins. 
2:00 PM 
60-minute, post-TSST assessment 
2:50 PM 
ASP Ends. 
 
2:50-3:20 PM 
Sensors removed; participant debriefing and 
compensation.  
 

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Table Key: UDS=Urine Drug Screen; CO= Carbon Monoxide; NWSC=Nicotine Withdrawal Symptom Checklist; STAI=State-Trait 
Anxiety Inventory; DDT = Delay Discounting Task; CQ=Craving Questionnaire; CREMA=Cue Reactivity Ecological Momentary 
Assessment; HR=Heart Rate; SC=Skin Conductance; BP=Blood Pressure; SRT=Smoking Resistance Task; ASP=Ad libitum 
Smoking Period.  
The participant will then complete the Smoking Resistance Task (SRT), which is a empirically validated 
laboratory model of smoking lapse behavior (McKee, 2009; McKee, Krishnan-Sarin, Shi, Mase, & O'Malley, 
2006; McKee, et al., 2011). The task involves testing the ability of overnight abstinent smokers to resist smoking 
in a situation where they are free to smoke but continued abstinence is reinforced with money. In the present 
case, a participant’s preferred brand of cigarettes and a lighter will be presented on a tray.  The experimenter 
will explain that the participant may begin smoking at any time, but the participant will be eligible to earn $1.50 
for every 5 minutes the participant is able to “resist” smoking (up to a total of 50 minutes or $15).  Once (s)he 
elects to smoke, the participant will begin the Ad libitum Smoking Period (ASP), in which (s)he is permitted to 
smoke as much as desired over the next hour in the laboratory. Topographical features of smoking behavior will 
be measured using the CReSS Pocket (CReSS, Borgwaldt KC, Inc., Richmond, VA), a self-contained, battery-
operated device. In addition, the experimenter will record the number of cigarettes smoked. 
Oxytocin/Placebo Administration: As noted above, participants will be administered 40 IUs of oxytocin or 
matching placebo nasal spray at approximately 12:00 noon. This dose and timing of administration was selected 
based on previous studies that have used similar doses of oxytocin (Ditzen et al., 2009; Heinrichs, et al., 2003; 
Macdonald et al., 2011), as well as our own previous pilot work (see Preliminary Data).  Intranasal oxytocin and 
matching placebo will be compounded by MUSC Investigational Drug Service (IDS).  The concentration of 
oxytocin will be 40 IUs/ml. Randomization will be done by the MUSC Investigational Drug Service, who will keep 
a record of the blind and be available should unblinding be necessary. 
C3g. Instruments/Measures. 
The diagnostic instruments/assessments employed in this investigation are widely cited, standardized 
instruments that have strong psychometric properties. This project has several instruments in common with 
Projects 1 in an attempt to foster assessment synergy between clinical projects. A brief description of each 
measure is as follows (where possible, instruments are grouped according to purpose and/or timing of use): 
i. Initial General/Diagnostic Assessments: Demographic and Medical Information Assessment Form will be used 
to assess standard demographic information at baseline (using the NIH race/ethnicity categories) and medical 
history; Mini-International Neuropsychiatric Interview or MINI (Sheehan et al., 2003; Sheehan et al., 1998) will 
be used to assess general psychiatric functioning and DSM-IV diagnostic status, including alcohol and other 
drug abuse and dependence; Structured Clinical Interview for DSM-IV (SCID-I/P) is a structured diagnostic 
interview that assesses each of the criteria for DSM-IV diagnoses. The substance use disorder modules from 
the SCID are used as an alternative for these modules in the MINI.  The SCID has proven to have excellent inter-
rater and test-retest reliability (First et al., 2002); Daily Hassles Scale (DeLongis, Folkman, & Lazarus, 1988) 
consists of a list of  irritating, frustrating or distressing events that characterize everyday interactions with the 
environment (participants rate both frequency and intensity of events for the past month); Adverse Childhood 
Experiences Questionnaire and ACE Brief (ACE; Felitti et al., 1998) assess childhood maltreatment and 
exposure to household dysfunction (employing the ACE will allow for potential cross-SCOR collaborations as it 
also being employed by the UCLA SCOR); Toronto Alexithymia Scale (TAS-20, Bagby, Parker & Taylor, 1994) 
is a scale which measures alexithymia, a condition in which people have trouble identifying and describing 
feelings.  Items are rated using a 5-point Likert scale whereby 1 = strongly disagree and 5 = strongly agree. Both 
the original, 1985 version and the revised, 1992 version will be administered at the assessment visit; Modified 
Cigarette Evaluation Questionnaire (mCEQ, Rose, Behm, & Westman, 1998; Brauer, Behm, Westman, Perkins, 
& Rose, 2001) is a 12-item questionnaire assessing the reinforcing effects of smoking and contains 5 subscales 
(smoking satisfaction, psychological reward, enjoyment of respiratory tract sensations, craving relief, aversion) 
that will be given at screening, Day 7, and during the laboratory session post-cigarette during the ASP; The 
Distress Tolerance Scale (DTS, Simmons & Gaher, 2005) is a validated self-report which measures tolerance, 
appraisal, absorption, and regulation of emotional distress; Timeline Follow-Back (TLFB; Sobell & Sobell, 1992) 
is a calendar-based instrument with specific probes to obtain detailed information about substance use (including 
smoking) that will be used to assess smoking and other substance use in the three months prior to study 
involvement; Smoking History Form will be used to assess current smoking patterns, smoking environment, and 
previous smoking quit history; Fagerström Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, 
Frecker, & Fagerstrom, 1991) will be used to assess degree of nicotine dependence; Menstrual History Diary 

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will be used to assess the timing of the menstrual cycle of female participants for the 90-days prior to study entry 
and to track their cycle during study participation. The Pittsburg Sleep Quality Index will be used to assess sleep 
patterns (Buysse, et al., 1989). Anxiety and depression symptoms will be assessed through The Quick Inventory 
of Depressive Symptoms (Rush, et al., 2003) and from the PROMIS© item bank (US DHHS).  Daily stress will 
be obtained using the 10-item Perceived Stress Scale (PSS; Cohen et al., 1983). The Life Events Occurrence 
Scale (Maciejewski,, et al.) will be used to inventory adult trauma. A brief survey from the National Health and 
Nutrition Examination Survey (CDC, 2000) will be used to rate quality of life. A body map will be used to rate 
areas of pain (Cleeland et al., 1989).  
 
 
Genetic Testing 
Consenting participants will have blood drawn for genetic testing.  This will typically occur during the assessment 
unless circumstances do not permit.  We plan to examine genes associated with stress and cigarette smoking. 
Our group has previously collaborated with Dr. Ananda Amstadter at Virginia Commonwealth University (VCU), 
whose research group is actively investigating genetic variations associated with stress and nicotine use. 
Samples will be collected and stored at the MUSC Clinical Neurobiology Lab and periodically shipped to Dr. 
Ananda Amstadter’s Laboratory at VCU for analysis. 
 
ii. Daily (Longitudinal) Assessments: Craving Questionnaire/CQ (Carter & Tiffany, 2001) is a 4-item self-
report questionnaire that assesses urge to smoke in all CREMA sessions. CREMA Stress/Mood Assessment 
(Warthen & Tiffany, 2009a; Wray, et al., in press) will assess stress, negative mood (“I am stressed, depressed, 
angry, worried, or frustrated”) and positive mood (“I am happy, joyful, or pleased”) during CREMA sessions. 
CREMA validity scales (Warthen & Tiffany, 2009a; Wray, et al., in press) assess distractibility and attentiveness 
during CREMA sessions using 5-point rating scales (strong disagreement=1; strong agreement=5). As noted 
above, saliva samples will be collected on a daily basis in order to determine levels of estradiol (females only), 
progesterone (females only) and testosterone (males only). Qualified laboratory technicians at MUSC’s Clinical 
and Translational Research Center (CTRC) will perform all assays using commercially available immunoassay 
kits provided by Salimetricstm.  
iii. Laboratory Session Assessments: As above, the Craving Questionnaire (CQ) and the CREMA 
Mood/Stress Assessment will be used to assess craving/urge to smoke and stress/mood at multiple time points 
during the laboratory session, respectively; State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushene, 
Vagg, & Jacobs, 1983) will be administered at the beginning of the laboratory session to assess state anxiety 
levels; Mood Form is a 9-item form (Diener & Emmons, 1984) that will be administered at the beginning of the 
laboratory session and will provide an immediate, corroborative assessment of current positive and negative 
mood states; Nicotine Withdrawal Symptom Checklist/NWSC (Hughes, Hatsukami, & Skoog, 1986) will be used 
to assess several withdrawal symptoms (i.e., craving, irritability/anger, anxiety/tension, difficulty concentrating, 
restlessness, etc.) from 0 to 4 (0 = not present, 4 = severe) at the laboratory visit; Delay Discounting Task is a 
27 item form that will be measured before and after TSST and provides estimates of impulsivity and the degree 
to which participants discount future rewards;  Heart rate and skin conductance (indices of physiological arousal) 
will be measured repeatedly over the course of the laboratory session. Heart rate (HR) will be collected via two 
electrodes along the bottom of the participant’s ribcage, rather than on the participant’s forearm, to minimize 
movement artifacts while skin conductance (SC) will be recorded using Ag/AgCl electrodes attached to the 
second phalanx of the first and third fingers of the non-dominant hand (HR and SC signals will be amplified using 
the ECG 100c and GSR 100c Modules of the Biopac MP100 data acquisition system); Blood pressure (BP) will 
be measured repeatedly via a non-invasive arm cuff; Cortisol levels will be determined via salivary samples 
collected at regular time intervals over the course of the laboratory session (they will be processed at the CTRC 
as described ii. above); Penetration of the Blind Questionnaire will be used to assess patient’s opinion regarding 
whether they were administered the study medication or placebo; Adverse Events (AE) form will be used to 
document any participant-reported adverse events, whether related or unrelated to session procedures, including 
intranasal oxytocin or placebo administration. 
C3h. Participant Compensation. 
Participants will receive $100.00 for completing the comprehensive assessment. They will also receive $50 
for attending the training visit and each interim visit (at Day 7); to incentivize compliance with the salivary data 
collection procedures, participants will be paid $5.00 per each day’s useable saliva sample delivered at the 

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interim visit. In the interest of incentivizing attendance at the laboratory session and in recognition of the fact that 
this session involves exposure to a stressor and a significant time commitment, participants will be paid $100.00. 
Since participants will be delivering their saliva samples (obtained over the previous week) when they attend the 
laboratory sessions, they will be paid an additional $5.00 for each useable daily sample they provide. Given that 
the laboratory session will involve the administration of the smoking resistance task (SRT), it will be possible for 
participants to earn up to $15.00 if they successfully resist smoking for the entire 50 min. resistance period. As 
noted above, the completion of CREMA sessions will be incentivized by paying participants $1.25 for each 
session with complete data. Participant travel expenses up to $50 are allowable on an as needed basis. Thus, 
maximum remuneration for study participation is $510. 
C3i. Sample Size Determination. 
This study is powered to test the hypothesis that non-cigarette-deprived females will be more reactive to 
smoking cues than males, as measured in the natural environment of smokers via CREMA technology. However, 
the sample size obtained for this is adequate to test all the four hypotheses with at least 80% power. The 
justifications for the power calculations are as follows. A recent study (Heishman, et al., 2010) found that non-
cigarette-deprived females responded to smoking cues with 10% greater craving than males (i.e., 10-unit 
difference on a 100-mm VAS), with this difference corresponding to an effect size of d = 0.7.  Since the proposed 
design intends to assess gender differences in a non-laboratory setting, we have reduced the expected effect 
size by 30% to 0.50. Based on the four-item subscale of the QSU (cf., Warthen & Tiffany, 2009b) to be used in 
the proposed study, a comparable detectable gender difference would be 0.45 (sd=0.9).  Accounting for the 
multiple correlated measures within each participant (i.e., reactivity will be measured multiple times daily for 14 
days using CREMA) through a between-observation correlation (autocorrelation) of 0.70, a sample of 96 females 
and 48 males is necessary to achieve 90% power (with a two sided type I error rate of 0.05) to detect the minimum 
relevant effect size of d=0.50. It is estimated that up to 20% of the participants may be lost before completion of 
the study.   
Assuming 144 participants complete all study procedures (accounting for 20% dropout), we will also have 
80% power with a type I error of 0.05 to detect a minimum effect size of d=0.50 between females and males in 
stress and craving response to the TSST and similarly between the oxytocin and placebo groups.  
C3j. Data Management & Statistical Analysis.  
Data Management 
All paper-based assessments will be entered into SPSS databases using dual data entry methods for 20% 
of cases. Semi-annual database management and data integrity audits will be conducted. Hormone and cortisol 
data will be obtained from MUSC’s CTRC in pre-formatted data files. HR and SC data will be acquired via 
specialized software and hardware (Biopac Systems, Inc.) interfaced with a computer. Standardized file formats 
will facilitate the rapid determination of summary values to be used for analysis purposes. The CREMA data will 
be automatically uploaded to a server on a daily basis and will be stored in a standard file format (to be 
determined in collaboration with Dr. Metts (Founder of Slicker Interactive & CREMA software developer). All data 
will be de-identified using participant ID number. 
Statistical Analysis 
Univariate descriptive statistics and frequency distributions will be calculated for all variables.  Departures 
from distributional assumptions for the proposed parametric methods will be identified and appropriate 
transformations of the data will be applied or alternative procedures (semi/non parametric methods) will be 
employed.  Baseline values for demographic, clinical, and other prognostic variables will be compared for 
imbalance across gender and treatment groups. These analyses will identify potential confounding variables to 
be used as covariates in subsequent analysis. 
Aim 1: Hypothesis 1 - To test the overall hypothesis that females will be more reactive than males to stressful 
and smoking-related cues presented in the natural environment, a linear mixed effects model will be employed. 
The dependent variable will be craving and the primary independent variable will be gender.  In the modeling 
process, within-subjects factors of stimulus type (active and neutral cues) and presentation order will also be 
included.   
Hypothesis 2 - To test the hypothesis that the estradiol to progesterone ratio will be positively related to cue-
elicited craving in the natural environment, salivary hormone levels and craving in response to the CREMA 
picture cues will be assessed over 14 days.  Hormone curves do not behave in a linear fashion, but may, in the 
example of progesterone, behave in a quadratic fashion preceding menses and a linear fashion following 

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menses.  Linear models may thus be inappropriate.  Traditional analyses group the hormone curves based on 
the estimated phases of women’s menstrual cycle (follicular and luteal) for the analyses. In addition to performing 
the data analyses using the same method, analysis will be extended to incorporate the non-linear patterns of an 
individual’s hormone profile. This method will be based on a non-linear regression model that has two to three 
segments, each one of which may be either quadratic or linear (Marrie, Dawson, & Garland, 2009). The ‘joint-
points’ at which the segments meet, which are referred to as knots, will also be treated as unknown and 
determined through the modeling process. After identifying the segments, regression models assessing hormone 
measures against the outcome (e.g., cue-elicited craving) in each segment will be assessed and the results 
interpreted accordingly. 
Aim 2: Hypotheses 1 and 2 - To test for gender and medication (oxytocin versus placebo) effects on reactivity 
profiles to the TSST during the laboratory session, a linear mixed effects model in which the dependent variables 
of interest are craving, stress and neuroendocrine (cortisol) response, and the primary independent fixed effects 
are gender, treatment group, and a random subject effect will be utilized. To account for the repeated measures, 
a covariance pattern for the error structure (such as an AR(1)) will be considered. The primary goal of this 
analysis will be to determine if the response to TSST is significantly different between females and males and/or 
significantly different between those who received oxytocin versus placebo (main effects of gender and 
medication). Additionally, as a secondary analysis, the interaction between gender and medication condition will 
be explored. 
To test the hypothesis that females will have a shorter latency to return to smoking than males, a discrete 
analog to the Cox proportional hazards model will be used. A complementary log-log model for interval censored 
survival times will be employed (Allison, 1982; Prentice & Gloeckler, 1978) that will take into account the interval 
nature of the time frame within which the return to smoking occurs. Also considered will be standard Cox 
proportional hazards models to compare time to begin smoking.  Puff intensity, flow rate, and number of puffs 
will be assessed using a topography device as participants smoke freely for 1 hour following the smoking 
resistance task. Longitudinal data analytic methods will be applied to the craving, stress and cortisol data 
obtained during the laboratory session for all time points before and after the TSST. 
Hypothesis 3 - To test the association between the estrogen to progesterone ratio and laboratory stress 
reactivity in women, a linear model will be developed to assess the relationship between hormones and 
subsequent stress reactivity. The dependent variables of interest will be the craving, stress and neuroendocrine 
(cortisol) response to the TSST while the independent variables will include the change in the hormone ratio over 
the week preceding the lab visit as well as the hormone ratio on the day of the visit.  Assumptions such as 
linearity of the relationship between the hormones and reactivity measures, homoscedasticity, and normality of 
the error distribution will be assessed and variables will be transformed as necessary. 
C3k. Operational Plan and Research Timetable.  
Organizational meetings to plan the structure/content of the CREMA software application and to establish 
milestones will begin immediately upon notice of award. Dr. Metts (Slicker Interactive) will deliver a demo 
application at 3-months and pilot work will be conducted. The final product will be delivered/operational within 
the first 5 months of the grant tenure period. Because we already have ongoing cue/stress reactivity studies with 
smokers, trained personnel, an active recruitment strategy, and the TSST procedures well established, we 
anticipate that no more than 6 months startup will be necessary before recruitment can commence. At a rate of 
3-4 participants per month, we should have no difficulty completing study recruitment during the expected 51-
month recruitment period. This will allow 3 months for data reduction, management, analysis and manuscript 
preparation. A follow-up proposal will be planned and prepared in tandem with manuscripts. 
 
Human Subjects Research. 
Protection of Human Subjects. 
1. Risks to the participants. 
Drs. Saladin and Gray and their research team have completed the University of Miami computer-based 
training course CITI Human Subjects Research Education Course.  All research activity, informed consents and 
continuing reviews will be reviewed by MUSC’s IRB in compliance with 45CFR46 before the research is started 
and continuing review will occur annually.  Drs. Saladin and Gray will ensure that all information needed for the 
continuing review is at the IRB in accordance with IRB requirements. 

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1.1 Human Subjects Involvement and Characteristics.   
 
A total of 120 female and 60 male nicotine dependent smokers, between the ages of 18-45, will be recruited 
over a 51-month period.  The sample size was determined based on statistical power analysis (details provided 
in Data Analysis Section). The inclusion/exclusion criteria are as follows: 
Inclusion criteria: 
a) Females and males age 18 – 45 who smoke at least an average of 5 cigarettes per day for at least past 
6 months 
b) Females must be post menarche and pre menopausal, have a regular menstrual cycle between 25 and 
35 days, and, if recently pregnant, be at least three months post delivery/breast feeding 
c) Participants must submit a carbon monoxide sample of ≥ 5 ppm at their screening visit 
Exclusion criteria: 
a) Any serious or unstable medical or psychiatric disorder that may, in the judgment of the study physician, 
interfere with study completion  
b) Participant meet criteria for PTSD  
c) Any medication (e.g., propranolol) that may interfere with psychophysiological (e.g., heart rate) 
monitoring 
d) Current substance dependence  other than nicotine and caffeine use, in the past month 
e) Use of other tobacco products 
f) Females  that are  pregnant, breast feeding, status post hysterectomy or bilateral oophorectomy, or taking 
birth control or hormone replacement medication that would affect the menstrual cycle 
g) Males  that are status post orchiectomy 
1.2 Sources of Research Material.   
Research material obtained from the individual subjects include physical and psychiatric examination results, 
drug (including nicotine) use assessment results, expired air breathalyzer alcohol and CO tests, saliva samples 
(for progesterone, estradiol, testosterone, cortisol, and cotinine), heart rate, skin conductance, and subjective 
ratings (e.g., craving).  Urine samples for the urine drug screen, pregnancy assessment and cotinine analysis 
will also be obtained. Research data will be obtained specifically for research purposes. We will not use existing 
specimens, records or data.  
1.3 Potential Risks. 
Questionnaires and interviews are all non-invasive and, as such involve minimal physical risk to the 
participants.  Potential risks incurred by participants include: 
a) Loss of confidentiality: There is a risk of loss of confidentiality regarding the information obtained during 
study participation. 
b) Craving and stress induction: There is a risk of increased stress and craving for cigarettes as a result of 
the cue-reactivity procedures.     
c) Oxytocin: Participants will be given a single intranasal administration of oxytocin or placebo (double blind) 
during the laboratory session.  There is potential for adverse effects associated with intranasal oxytocin, 
though a recent review of controlled human studies revealed minimal adverse effects, with rates 
equivalent to placebo (Macdonald et al., 2011). The most frequent adverse effects included (1) 
lightheadedness, drowsiness, and/or headache (in 6% of participants), (2) increased calmness/euphoria, 
feeling more comfortable or having more energy (in 5% of participants), and (3) nasal irritation and/or dry 
mouth/throat (in 3% of participants). 
d) Venipuncture: The risks of drawing blood include temporary discomfort from the needle stick and bruising. 
e) Adverse events unrelated to study participation may occur during the course of study participation. 
There are no alternative methods of obtaining this information. 
2. Adequacy of protection against risks. 
2.1 Recruitment and Informed Consent Procedures.   
Recruitment of the subjects will be from the community by media advertising, word of mouth, flyers, broadcast 
emails, media articles, and clinical referrals.  Medical University of South Carolina IRB approved Informed 

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Consent (IC) will be obtained prior to the initial assessment.  The consent will be explained orally and in written 
form, and will be documented by the signature of the participant on the IC.    
Absence of Coercion: Participation in the study is voluntary.  Participants will be compensated up to $460 if 
completing all study procedures, an amount commensurate with the necessary commitment of time and effort.  
The informed consent agreement that will be read to each person prior to his or her enrollment in the study 
explains the following: 
a) Compensation will be provided for assessment and various study procedures and visits.  
b) Participants may discontinue participation in the study at any point. 
c) Withdrawing from the study will not result in any adverse consequences to the participants. 
2.2 Protection Against Risks. 
The research staff will closely supervise all participants entering into the study.  Every effort will be made to 
protect study participants from harm.  MUSC abides by federal regulations governing the protection of special 
populations including women and children. Potential risks associated with participation in this study are:  
a) Loss of confidentiality: The research materials will become a part of the modern record keeping facility of 
the Institute of Psychiatry (IOP), which will minimize risks to the privacy of the subjects.  In addition, we 
will obtain a Certificate of Confidentiality from the NIH to protect participants’ information to the extent of 
the law. 
b) Craving induction: While there is a small risk of increased stress and craving for cigarettes as a result of 
the cue-reactivity procedures, it does not appear to differ substantially from the reactivity elicited by stimuli 
commonly encountered in the day-to-day environment of the study participants. Participants that report 
significant stress or craving after the laboratory session will be provided a debriefing session to address 
symptoms.  
c) Oxytocin: Given the benign safety profile of single-dose intranasal oxytocin (MacDonald et al., 2011), we 
anticipate minimal adverse effects.  Nonetheless, the study medical clinician will monitor, record, and 
address any adverse effects experienced by participants.   
d) Venipuncture: The optional blood draw for genetic testing will be conducted by an experienced 
phlebotomist with all required training and certification.  Any concerns or issues related to the blood draw 
will be addressed as needed. 
e) Serious adverse events will be reported to the NIDA project officer, in addition to the local IRB and FDA 
as appropriate. 
3. Potential Benefits of the Proposed Research to the Participant and Others. 
A potential benefit is that research participants may learn about the types of cues that trigger their smoking 
cravings and this may be useful in helping them to avoid and/or cope with smoking triggers in their day-to-day 
life. Other benefits of study participation include access to assessment information pertaining to physical and 
mental health and wellness, substance use/misuse, etc. Also, regular contact with and monitoring by research 
staff may serve to assist participants in future attempts to abstain from cigarette use.  Overall, given the potential 
benefits, it would appear that exposure to the risks associated with study participation are well justified.  The 
risk/benefit ratio appears to favor the study participant.  
4. Importance of the Knowledge to be Gained. 
The knowledge gained from this study may serve to inform the clinical treatment of smoking by elucidating 
gender and sex hormone influences on stress, craving, and smoking behavior. Additionally, the study will allow 
for exploration of oxytocin as a potential pharmacotherapy targeting stress-related craving and smoking 
behavior.  This information could then be used to guide investigation of gender-optimized smoking cessation 
interventions.  Additionally, the proposed study will involve the collection of subjective and physiological reactions 
to stress and smoking cues, yielding important information about how gender and sex hormones influence these 
reactions.    
5. Data and Safety Monitoring Plan. 
This section is based on the recommendations in NIDA’s “Guidelines for Developing a Data and Safety 
Monitoring Plan” (www.drugabuse.gov/funding/dsmbsop.html).  

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5.1 Summary of the Protocol.   
This application proposes a combined naturalistic and laboratory approach to investigate gender, sex 
hormone, and oxytocin influences on cue-responsive craving and smoking behavior.  Inclusion/exclusion criteria 
are outlined above. 
5.2 Trial Management.   
The study will be managed from the Division of Clinical Neuroscience within the Department of Psychiatry 
and Behavioral Sciences at the Medical University of South Carolina.  The target population is described above 
in the inclusion/exclusion criteria. 
5.3  Data Management and Analysis. 
Data will be entered by research assistants directly into a computer using standard database software.  The 
data analysis plan is outlined in the Data Management & Statistical Analysis section.  
5.4 Quality Assurance. 
Dr. Saladin (PI) and Dr. Gray (Lead Co-I), will have weekly meetings with the research assistants to discuss 
qualitative comments received during data collection and any problems in data collection.  The statistician will 
periodically examine the database to look for irregularities.  Initial data analyses will examine distributions of 
variable scores, and comparability of baseline characteristics across conditions in case analyses need to be 
adjusted for these.  Confidentiality protections are outlined above. 
5.5 Regulatory Issues. 
Prior to the start of the study, the protocol will be registered in the Clinical Trials Registry.  We will notify FDA 
to assess the need for an IND.  All unexpected AEs will be reported to the MUSC Committee on Human Research 
and NIDA within 48 business hours.  Serious AEs will be reported within 24 business hours.  Follow-up of all 
unexpected and serious AEs will also be reported to these agencies.  All AEs will be reviewed weekly by Dr. 
Gray and yearly by the IRB.  Any significant actions taken by the local IRB and protocol changes will be relayed 
to NIDA.  Potential conflicts of interest will be reported using standard rules for disclosure.  Adverse Events 
(AEs)/Serious Adverse Events (SAEs) occurring during the course of the study will be collected, documented, 
and reported in accordance with protocol and IRB reporting requirements.  All research staff involved with 
adverse event reporting will receive general and protocol specific AE/SAE training including identification, 
assessment and evaluation, and documentation and reporting.  A research assistant will identify any potential 
adverse events during the course of the study from participant self-report and administration of the visit 
assessments and procedures.  The research assistant will provide information to a study medical practitioner, 
who will be responsible for AE/SAE assessment and evaluation including a determination of seriousness and 
study relatedness.    
5.6 Definition of AE and SAE. 
An Adverse Event (AE) is defined as any untoward medical occurrence in a study subject administered a 
pharmaceutical product that does not necessarily have a causal relationship with this treatment (ICH GCP).  Any 
unwanted change, physically, psychologically or behaviorally, that occurs in a study participant during the course 
of the trial is an adverse event.  A Serious Adverse Event (SAE) is defined as an adverse event that has one of 
the following outcomes: 
- 
Results in death, 
- 
Is life-threatening, 
- 
Requires inpatient hospitalization or prolongation of existing hospitalization, 
- 
Results in persistent or significant disability/incapacity, 
- 
Is a congenital anomaly/birth defect. 
OR 
- 
Requires intervention to prevent one of the above outcomes. 
5.7 Documentation and Reporting. 
AEs/SAEs are documented and reported as per protocol and IRB requirements.  Research staff will identify 
adverse events and obtain all available information to assess severity, seriousness, study relatedness, 
expectedness, outcome and the need for change or discontinuation in the study intervention.  Adverse events 
are generally documented on AE Logs and AE Case Report Forms (CRFs).  Additional relevant AE information 

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if available should be documented in a progress note in the research record as appropriate to allow monitoring 
and evaluating of the AE.  If the AE meets the definition for serious, appropriate SAE protocol specific reporting 
forms are completed and disseminated to the appropriate persons and within the designated timeframes as 
indicated above.  For each AE/SAE recorded, the research staff will follow the AE/SAE until resolution, 
stabilization or until the participant is no longer in the study as stated in the protocol. 
When a reportable SAE is identified, the research assistant will initiate an SAE form, and the following 
individuals will be notified by facsimile transmission within 24 hours of the site’s initial notification of the SAE:   
a) The Principal Investigator(s) and the study safety officer at the site will provide oversight, consultation, 
assessment and documentation as appropriate of the SAE.    
b) The research staff will notify the MUSC institutional review board (IRB) and complete the AE report form 
in conjunction with a study medical practitioner.  The MUSC IRB meets monthly and is located at 19 
Hagood Avenue, Suite 601, MSC857, Charleston, SC  29425.  Communication with the IRB is through 
email, memos, official IRB forms, and online reporting. 
c) The NIH program officer. 
If complete information is not available when the initial 24-hour SAE report is disseminated, follow-up 
information will be gathered to enable a complete assessment and outcome of the event.  This information may 
include hospital discharge records, autopsy reports, clinic records, etc.  The research staff will attach copies of 
source documents to the SAE report for review by a study medical practitioner for forwarding to the NIH program 
officer as appropriate within 2 weeks of the initial SAE report.  In addition, a study medical practitioner will provide 
a signed, dated SAE summary report, which will be sent to the NIDA Medical Safety Officer within two weeks of 
the initial SAE report.   
We will report adverse events to the Medical University of South Carolina (MUSC) Institutional Review Board 
(IRB) online as soon as possible, but no later than 10 working days after the investigator first learns of the event.  
The MUSC IRB AE reporting requirements are as follows:  All deaths that occur during the study or 30 days post 
termination from the study are required to be reported as adverse events even if they are expected or unrelated.  
Other adverse events are reportable to the MUSC IRB if the AE is unexpected AND related or possibly related 
AND serious or more prevalent than expected.  All three criteria must be met for an AE to be reported to the 
MUSC IRB.  The IRB definition of unexpected is that the AE is not identified in nature, severity or frequency in 
the current protocol, informed consent, investigator brochure or with other current risk information.  The definition 
of related is that there is a reasonable possibility that the adverse event may have been caused by the drug, 
device or intervention.  Reportable AEs are reviewed by the IRB Chair and reported to the IRB Board at the next 
meeting.     
5.8 Trial Safety. 
The potential risks and benefits and methods to minimize these risks are outlined above, and the methods 
of collecting AEs are described in the research design.  The research staff will report any unexpected AEs or 
any scores of “severe” on the side-effect symptom rating form or any FDA-defined serious AEs to a study medical 
practitioner within 24 hours so that they can decide on the appropriate action.  All unexpected AEs will be 
monitored while they are active to determine if treatment is needed. AEs will be coded on a weekly basis using 
the FDA’s COSTART rules (Center for Drug Evaluation and Research, 1993) and entered into a database.  For 
each weekly study meeting, the research assistants will prepare a summary of all AEs, including their severity, 
presumed relation to drug intake, and whether they caused a dropout or required treatment.  A study medical 
practitioner will review this at the weekly study meeting (or before if more urgent).  At the weekly meeting (or 
before if urgent), research assistants will report any premonitory symptoms of emergence of a mental disorder 
such as depression or alcohol dependence.    
Study procedures will follow as much as possible the FDA’s Good Clinical Practice Guidelines 
(www.fda.gov/oc/gcp) plus we have found using Spilker’s comprehensive text on conducting clinical trials useful 
(Spilker, 2000).  We will encourage participants to notify their physician that they are in a research study and 
that the physician should contact the study medical practitioner directly if he/she has any questions. 

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The research assistants will be instructed not to reveal whether a person is a participant in the study and will 
report to a study medical practitioner any outside requests for information about a participant or any breaches in 
confidentiality.  All requests by participant’s physicians and other medical providers will be referred directly to a 
study physician.   
5.9 Trial Efficacy.   
Final analyses, inclusive of fully unblinded oxytocin versus placebo effects on stress reactivity and craving, 
will occur after all participants have completed the study. 
5.10 DSM Plan Administration. 
The PI and Lead Co-I will be responsible for monitoring the trial. The statistician will examine (monthly) the 
outcomes database for missing data, unexpected distributions or responses, and outliers.  A DSM report will be 
filed with the IRB and NIDA on a yearly basis, unless greater than expected problems occur.  The report will 
include participant characteristics, retention and disposition of study participants, quality assurance issues and 
reports of AEs, significant/unexpected AEs, and serious AEs.  We will report main outcomes, including effects 
of oxytocin versus placebo on stress-reactive craving, at the end of the trial. 
5.11 DSM Board. 
We will seek guidance during discussion with the program officer on the potential necessity of convening a 
data and safety monitoring board for this project. 
5.12  Risk Benefit Ratio. 
 
The assessments and questionnaires are non-invasive and have inherently minimal risks.  Potential risks of 
concern are loss of confidentiality, increased stress and craving associated with cue reactivity procedures, and 
adverse events associated with oxytocin.  As discussed above, our research team will attempt to minimize these 
risks.  The relationships between stress, craving, and smoking behavior, and the underlying influences of gender 
and sex hormones, are poorly understood.  Investigation in this area will be critical in addressing gender-related 
health disparities in smoking, the leading cause of preventable death in the US.  Knowledge gained by the 
proposed study will help fill an important void in research on treatments for nicotine dependence. 
 

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