Imaging Extrastriatal Dopamine Release in Tobacco Smokers and Nonsmokers
Conditions: Nicotine Dependence
Sponsor: Yale University

 
 
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Title: Imaging Extrastriatal Dopamine Release in 
Tobacco Smokers and Nonsmokers 
 
NCT: NCT02348385 
 
Principal Investigator: Kelly Cosgrove 
 
Latest Approval Date: 08/22/2017 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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 RESEARCH PLAN 
 
1. Statement of Purpose: State the scientific aim(s) of the study, or the hypotheses to be tested. 
 
Our goal is to examine sex differences in amphetamine-induced dopamine (DA) release in 
tobacco smokers and nonsmokers. 
 
Specific Aim 1: To determine sex differences in amphetamine-induced dopamine release in 
healthy tobacco smokers and nonsmokers. 
[11C]FLB-457 has been used in several PET centers and has recently been approved for use at the 
Yale University PET Center (HIC#100900739, PI: Cyril D’Souza). We would like to determine 
whether there are sex differences in amphetamine induced DA release in healthy tobacco 
smokers and nonsmokers. Specifically, 40 healthy tobacco smokers and 40 healthy nonsmokers 
will have an magnetic resonance imaging (MRI) scan followed on another day by two [11C]FLB 
scans (ideally, the two PET scans will be carried out in the same day). Up to 3 hours before the 
second PET scan, amphetamine (0.4mg/kg, PO) will be administered. Smokers may be asked to 
return for a second MRI scan 3-5 weeks after their PET scans. We hypothesize women will have 
greater amphetamine-induced DA release than men in extra-striatal brain regions.  
 
2.   Background: Describe the background information that led to the plan for this project.    
      Provide references to support the expectation of obtaining useful scientific data.  
 
Tobacco Smoking: Tobacco smoking continues to be a major health problem. Despite the 
overwhelming evidence of the medical risks associated with tobacco smoking, approximately 20-
25% of the adult US population continues to smoke and the vast majority of those who do 
attempt to quit relapse within the first month(1).  Nicotine is the main active and addictive 
chemical in tobacco and acts as an agonist at the ß2subunit containing nicotinic acetylcholine 
receptor (ß2-nAChR). The few existing approved medications for tobacco smoking cessation 
(including various forms of NRT and bupropion) are minimally effective at preventing relapse; 
however, varenicline (Chantix) shows greater promise. There is an urgent need to understand 
the fundamental brain mechanisms involved in tobacco smoking to direct future 
medications development. The studies herein are a first step.  Specifically, we will determine 
sex-differences in amphetamine-induced dopamine release at “baseline”.  In a future study, we 
will then treat tobacco smokers with smoking cessation medication and determine if their 
amphetamine-induced DA release is reduced.  Our long-term goal is to establish whether certain 
medications are effective by reducing drug-induced DA release, i.e., the drugs make cigarette 
smoking less rewarding.  
Amphetamine-induced DA release. Due to the difficulty and unreliability of obtaining nicotine- 
or tobacco smoking-induced dopamine release, the majority of PET studies examining changes 
in synaptic DA levels have relied on amphetamine.  Amphetamine, as opposed to nicotine, acts 
directly at the DA-ergic system and is a potent reuptake inhibitor of dopamine and a dopamine 
releaser.  While nicotine results in 200% increases in dopamine release as measured with 
microdialysis, amphetamine results in up to 1000% increases in dopamine release(2).  Therefore, 
there is a much larger signal to detect, which has been reliably measured in many PET 
studies(19-25).  In the current study, we will use amphetamine-induced DA release to measure 
DA neurotransmission.  
 

 
 
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Measuring dopamine release in vivo with the occupancy model.  Typically, dopamine release 
has been most reliably measured using stimulants such as cocaine and amphetamine with 
[11C]raclopride PET or [123I]IBZM SPECT (see (22) for review).  Thus, challenges, e.g., 
injections of drugs that increase synaptic dopamine will interfere with radiotracer binding by 
decreasing the availability of the dopamine receptors to bind the radiotracer. This allows 
calculation of the “occupancy” of the receptors by dopamine or a change in binding potential, 
and is an indirect measure of dopamine release.  Specifically, in these studies, because synaptic 
dopamine will compete with [11C]FLB for high affinity D2/3 receptor binding, an increase in 
synaptic dopamine will result in a decrease in [11C]FLB binding potential.  
 
The exact mechanism by which the binding potential is reduced is unknown. It is most 
likely that synaptic dopamine interferes with radiotracer binding, but it is also possible that D2/3 
receptor internalization also plays a role in the prolonged reduction in binding potential, or 
displacement of [11C]raclopride after amphetamine injection(22, 26).  D2/3 or D2 receptor 
internalization after nicotine has not been reported. Currently, the occupancy model together 
with in vivo PET imaging provides a noninvasive technique for measuring drug-induced 
dopamine release.  
 
 [11C]FLB. [11C]FLB-457 ([11C]FLB) has advantages over the more typically used [11C]raclopride, 
because whereas [11C]raclopride is useful for measuring DA release in the striatum, [11C]FLB can 
be used to measure extra-striatal DA release.  The extra-striatal DA release most critically includes 
the prefrontal cortex and also other cortical areas and the thalamus.  A number of studies have 
determined that [11C]FLB is sensitive to amphetamine-induced DA release(27-29).  
Sex Differences. Nicotine replacement therapies (NRTs), e.g., nicotine patch, gum, lozenge, 
inhaler, as well as the nicotinic partial agonist therapy varenicline, are the most widely used 
treatments to help people quit smoking.  Many studies show that men respond better to NRT than 
women(30), and women often have a more difficult time quitting smoking than men(31-35). In a 
series of studies, Perkins and colleagues(36) demonstrated that men are better able to identify 
nicotine in a nasal spray and to discriminate nicotine from placebo than are women, indicating 
that men are better able to detect the interoceptive cues of nicotine. Consistently, women 
experience greater craving relief then men from a denicotinized tobacco inhaler(37), highlighting 
the role sensory cues play in nicotine dependence for women. These results are consistent with 
findings showing that women are more reinforced by the non-nicotine conditioned stimuli that 
are strongly associated with smoking than men, while men are more reinforced by the nicotine 
per se in cigarettes and in NRT than women(38).  
 
Sex differences have been reported in DA neurotransmission and receptor availability.  
Higher DA D2 receptor availability was found with [11C]FLB in women compared to men in the 
frontal cortex(39). Women also have higher striatal presynaptic dopamine synthesis capacity 
than men(40).  Sex differences have been reported in healthy (nonsmoking) men and women in 
amphetamine-induced DA release with two other PET radiotracers. Men had greater DA release 
in the ventral striatum than women when measured with [11C]raclopride PET(25).  Men had 
greater DA release in the dorsal striatum than women, and women had greater DA release in the 
globus pallidus and frontal gyrus than men when measured with [18F]fallypride PET(24).  Taken 
together this suggests that amphetamine-induced DA release is greater in men in the striatum, 
and in women in the frontal cortex.  Both of these areas are key players in the addiction to 
tobacco smoking.  This study will help shed light on the neurochemical mechanisms involved in 
the sex differences in tobacco smoking behaviors.  
 
3.   Research Plan: Provide an orderly scientific description of the study design and research  
      procedures as they directly affect the subjects.  

 
 
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3.1 Overall Research Design:  
Specific Aim 1: To determine sex differences in amphetamine-induced dopamine release in 
healthy tobacco smokers and nonsmokers. 
[11C]FLB-457 has been used in several PET centers and has recently been approved for use at the 
Yale University PET Center (HIC#100900739, PI: Cyril D’Souza). We would like to determine 
whether there are sex differences in amphetamine induced dopamine release in healthy tobacco 
smokers and nonmokers. Specifically, 40 healthy tobacco smokers and 40 healthy nonsmokers 
will have an MR scan followed on another day by two [11C]FLB-457 scans (ideally, the two PET 
scans will be carried out in the same day). Up to three hours before the second PET scan, 
amphetamine (0.4mg/kg, PO) will be administered. We hypothesize women will have greater 
amphetamine-induced DA release than men in extra-striatal brain regions. 
 
3.2 Subjects: 
Screening Evaluation   
Potentially eligible subjects will undergo an initial screening evaluation within 6 months of PET 
scanning, they may be recruited under HIC#0808004163 (PI:McKee). The purpose of this 
evaluation is to ensure that subjects meet study criteria (as listed above). After informed consent is 
obtained, a medical history, vital signs, complete physical examination, and ECG will be 
performed. Several laboratory tests will be performed at this visit, including a complete blood 
count (CBC), chemistry profile, thyroid function studies, serum ß-HCG (women only), urinalysis, 
and urine toxicology screen. All female subjects will undergo a serum pregnancy test at the time of 
screening. Additionally, urine pregnancy tests and urine drug toxicology screening will be done on 
the day of the PET scans before imaging.  
 
3.3 Assessments: 
All participants will be screened initially using a telephone screen that will include questions to 
evaluate medical history, personal and familial psychiatric and smoking history.  A wide range of 
measures, such as psychiatric and substance abuse history, medical assessments and affective 
symptoms including but not limited to the below will be measured during the intake evaluation 
and on the PET scan days. 
 
 
Procedures: 
 
Screening, Evaluation and Clinical Ratings 
Screening, evaluation and clinical ratings are obtained during the screening process, described 
above.  Subject may be screened under HIC#0808004163 (PI:McKee). 
 
Magnetic Resonance Imaging (up to 1 hour) 
Structural and functional (resting state) magnetic resonance imaging (MRI) scans (3 T) will be 
collected in each subject to co-register PET and MRI for image analysis. An MRI will be 
acquired at the Yale University MRI Center. Subjects will be taken through a ferromagnetic 
metal detector before entering the scan room. MR images provide a matching anatomical atlas 
for creating individualized region-of-interest templates for each subject.  Subjects may be asked 
to participate in up to two MR sessions (one MR prior to each PET scan date). 
 
 
 
 

 
 
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PET experiments  
PET experiments will be conducted at the Yale University PET Center.   
 
For Aims smokers and nonsmokers will have up to two [11C]FLB457 scans (2/day when 
feasible).  If technical difficulties arise the second PET scan will be rescheduled as soon as 
possible.   
 
We may ask subjects to refrain from eating 4-6 hours prior to injection and remain fasting until 
the study is over.  Subjects will also be asked to refrain from drinking caffeinated beverages that 
day.  Smokers may also be asked to abstain from smoking cigarettes starting at 10 p.m. the night 
before their PET scans day.  For all women, a urine pregnancy test will be performed at the 
beginning of the imaging day at the Yale PET Center. 
 
The preparation of the subject may include the placement of up to two venous lines and an 
arterial line.  The purpose of the arterial line is for blood sampling of [11C]FLB-457 to measure 
arterial concentration. The purpose of the two venous lines is for the [11C]FLB-457 injection and 
to measure amphetamine or nicotine levels, respectively.   
 
The arterial line may be placed after infiltration of the skin with 1 to 2% lidocaine by an 
experienced physician. A study physician or nurse will be present in the PET suite while the 
arterial line is in place. 
 
Partial immobilization of the head will be done using a felt chin strap. PET scans are acquired as 
subjects rest using the HR+ or HRRT scanner.  A transmission scan is obtained immediately 
before or after each emission scan.  
 
For the emission scans, 10 mCi or less of [11C]FLB457 will be injected intravenously.  
 
Up to two injections of [11C]FLB457 are administered to the subject for the emission scans.  
Following each injection, scan emission data will be acquired for up to 120 minutes. When 
possible both FLB scans will be performed on the same day, if the second scan is cancelled, e.g., 
the radiotracer synthesis fails, the second scan will be rescheduled as soon as possible on a 
different day, and the amphetamine or stress reactivity paradigm will be administered again, 
using the same protocol. For Aim 1, we will wait at least 4 days in order to allow the 
amphetamine to clear.  
 
At -1, 5, 20, 40, and 60 minutes post visualization, plasma samples will be obtained.  Plasma 
samples will be obtained to analyze for cortisol, ACTH, NE, EPI, and other stress related 
hormones.  We will assess hypothalamic-pituitary-adrenal (HPA) axis function using samples of 
adrenocorticotrophin hormone (ACTH) and cortisol and plasma norepinephrine (NE) and 
epinephrine (EPI) during the stress behavior challenges. 
 
Amphetamine administration (oral) 
Dextroamphetamine sulfate is the dextro isomer of the compound d,l-amphetamine sulfate, a 
sympathomimetic amine of the amphetamine group. It is an FDA approved drug available for the 
treatment of narcolepsy and attention deficit hyperactivity disorder (maximum approved total 
daily dose of 5-60 mg). After the first scan, dextro-amphetamine (0.4 mg/kg, PO) will be given 
in increments of 5 mg, as it is available in 5 mg tablets, and will be rounded up to approximate 
0.4 mg/kg total dose without exceeding it. The dextro-amphetamine will be given at 0.4mg/kg. 

 
 
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The total dextro-amphetamine dose will not exceed 40 mg per scan.  A second transmission and 
emission scan will be acquired 3-hours post amphetamine identical to the methods outlined 
previously. The timing of the second [11C]FLB 457 administration and subsequent PET scanning 
(i.e., 3 hours) corresponds to the time of maximum plasma concentration of amphetamine as 
stated in the respective FDA-approved product labeling. EKG and frequent BP monitoring may 
occur throughout the study and until the vital signs are within normal limits. Supplemental 
oxygen will be provided via nasal cannula if necessary.  If the systolic BP reaches or exceeds 
200 mmHg for more than 5 minutes, the study doctor will take the appropriate clinical measures 
in order to lower the BP, which may include phentolamine administration (5 mg IV over 10 min) 
or other appropriate measures.  
 
Following the post-amphetamine PET scan, subjects will be assessed (physical, EKG and vital 
signs) by one of the investigators.  Subjects will be discharged when vital signs are within 
normal limits and when behavioral changes (if any) are found to be not clinically significant by 
the MD attending to the subject at the PET Center. If subjects experience any adverse events, 
they will be treated until they become asymptomatic, prior to discharge. 
 
Behavioral response to amphetamine will be measured by self-ratings with a simplified version 
of the Amphetamine Interview Rating Scale (van Kammen and Murphy, 1975).  Four items will 
be investigated: euphoria ("feel good"), alertness ("feel energetic"), restlessness ("feel like 
moving") and anxiety ("feel anxious").  Self ratings will be obtained by analog scales at the 
following times relative to the d-amphetamine administration: -5 minutes, 0, and hourly 
thereafter until end of the second scan.  
 
Blood sampling 
During the [11C]FLB PET scans, samples may be drawn through the arterial line for 
determination of [11C]FLB arterial concentration. Samples will be drawn through a venous line 
to measure amphetamine levels. In the first phase of the study (5-10 min), the arterial input 
functions are measured with an automated blood counting system (PBS-101, Veenstra 
Instruments, Joure, The Netherlands) using a continuous withdrawal system where the 
radioactivity in whole blood is measured with a calibrated radioactivity monitor. Subsequently, 
individual blood samples may be taken at various time points and will be counted in a gamma 
counter.  Additionally, samples are centrifuged to obtain plasma, which will be counted in a 
gamma counter, and selected samples will be assayed for the presence of the parent radiotracer 
compound that has not been metabolized. These measurements will be performed by HPLC 
analysis. In addition, the fraction of plasma radioactivity unbound to protein will also be 
determined by ultrafiltration.  During the second, post-amphetamine [11C]FLB PET scan, up to 
15 blood samples will be collected  through a venous line for measurement of plasma 
amphetamine at selected time points following radiotracer administration.  
The total blood sampling volume drawn during the PET Day will be up to 295 mL (125 mL per 
PET scan) for [11C]FLB analysis, plus up to 100 mL for amphetamine analysis.  
 
Discharge 
After the completion of the two [11C]FLB PET scans, the catheters will be removed (arterial line 
will be removed by a nurse).  Subjects will be discharged from the PET suite, if they do not have 
a ride, a taxi cab will be called for them if they have had amphetamine. They will be called by a 
research staff member the following morning for a check on their health status.  
All subjects will be provided the telephone number of a research psychiatrist on call for any 
problems that arise in the immediate time period after discharge from the unit.  They will also be 

 
 
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given a discharge form that has specific instructions for calling one of the physicians if they have 
any questions or concerns following the study.  
 
Data analysis 
PET data will be reconstructed into images at Yale PET Center with all standard corrections 
using the appropriate reconstruction protocols and filters.  
 
 
Statistical Considerations: Describe the targeted number of subjects and the statistical  
     analyses that support the study design.  
 
Aim 1 is designed to obtain data in a sample size of 40 smokers and 40 nonsmokers, with 
equivalent numbers of men and women in each group. This is sufficient to determine whether we 
can reliably measure amphetamine induced dopamine release in vivo of at least 1000%, which is 
equivalent to a change in BPND of at least 20%. Regional [11C]FLB-457 uptake for each subject 
will be quantified as BPND described above for each ROI and will represent the primary outcome 
measure for the proposed experiments.  Repeated measures ANOVA will be used to evaluate the 
change between scans (deltaBP) for brain measures for the 80 pairs of scans.  Delta BP will be 
computed as [(BPbaseline-BPcondition)/BPbaseline X 100]. Analysis will be conducted using SAS 
version 9.1 (Cary, NC). N=40 subjects per group is necessary to detect sex differences.  
 
 
RESEARCH INVOLVING DRUGS, DEVICES, BIOLOGICS & PLACEBOS 
 
Identification of Drug, Device or Biologic: What is (are) the name(s) of the drug(s), device(s) 
or biologic(s) being used? Identify whether FDA approval has been granted and for what 
indication(s).  
 
[11C]FLB457 ((S)-(-)-N-([1-ethyl-2-pyrrolidinyl]methyl)-5-bromo-[C-11]-2,3-dimethoxybenzamide): 
2 injections of ≤10 mCi each of [11C]FLB457 will be administered to each subject. 
 
 
Application to the RDRC for use of the radiotracer [11C]FLB457 in this protocol will be submitted 
through the Yale-New Haven Hospital Radiation Safety Committee (Y-NHH RSC).  Approval will be 
obtained and submitted to the HIC at Yale.  
 
d-Amphetamine, dose 0.4 mg/kg, PO to healthy controls so no IND necessary 
 
 
   Background Information: Provide a description of previous human use, known risks, and data 
addressing dosage(s), interval(s), route(s) of administration, and any other factors that might 
influence risks. If this is the first time this drug is being administered to humans, include relevant 
data on animal models.  
 
The risks of [11C]FLB injection are radiation exposure and toxicology.   
 
Radiation exposure 
 

 
 
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Absorbed radiation dose calculation for [11C]FLB was provided to us by Raj Narendran, MD and 
Scott Mason, PhD. at the University of Pittsburgh in collaboration with Dr. Michael Stabin, 
Department of Radiology, Vanderbilt University (formerly at ORISE).  
 
Single Study Limit.  Biodistribution data for [C-11] FLB457 was obtained in female and male 
Sprague-Dawley rats.  The dose estimates indicate that the maximum, permissible single study 
dosage of [C-11]FLB457 in human subjects, to remain below the 21 CFR 361.1 dose limit, is 20 
mCi (i.e., calculations based upon the ovaries as the critical organ; 3 rem per single study limit 
and 7.39 x 10-2 rad per mCi of [C-11]FLB457 to the ovaries of female subjects).  The female 
dose estimate is the worst case, as dose estimates to the critical organ of male subjects (the 
kidneys; 2.73 x 10-2 rad per mCi [C-11]FLB457) were less than that to the critical organ of 
female subjects. Thus, the dose of up to 10 mCi per single injection, or up to 20 mCi for the 
whole study (2 injections) is below this limit. 
 
Yearly Cumulative Exposure. The radiation exposure from all radiotracer injections (2 total) 
indicates that the total exposure resulting from the study (2 * 10 mCi) will remain well below the 
FDA 21 361.1 dose limits for yearly cumulative exposure to research subjects (dose limits of 5 
rads per year for whole body, active blood forming organs, lens of the eye and gonads; 15 rads 
per year for other organs). See table: limiting organ is ovaries for women, and kidneys for men. 
 
Toxicology 
The dose of FLB457 used in this study is a trace amount and is negligible (≤ 0.6 µg per 
administration) and is expected to induce less than 5% occupancy of D2 receptors. The use of 
[11C]FLB-457 at a tracer dose is not known to cause any clinically detectable effect in human 
beings. In 12 human studies at the University of Pittsburgh (total of 24 human injections), Dr. 
Raj Narendran did not observe any subjective or objective effects from administration of 0.6 µg. 
However, the risk of an idiosyncratic reaction is acknowledged in the consent form. Any 
significant adverse reaction will be reported to the FDA and the IRB. 
 
 
d-Amphetamine: 
 
Amphetamine is administered to measure changes in [11C]FLB-457 binding due to dopamine 
release. This dose was chosen because it is expected to produce a quantifiable displacement of the 
radiotracer. The risks are outlined in Section VI.  Oral(20, 24, 27, 59) and IV(19, 25, 60, 61) d-
amphetamine administration to healthy humans and individuals with psychiatric disorders has been 
safely used in many PET imaging studies. We will use the oral route due to the greater safety and 
ease of administration. 
 
   Source:  a) Identify the source of the drug, device or biologic to be used.  
[11C]FLB will be manufactured on site in the radiochemistry lab of the Yale University PET 
center. 
The radiotracer will be administered by PET Imaging technologists in the Yale PET Center. 
The radioligand is produced according to the local Standard Manufacturing Procedure and to 
local quality control procedures in effect at the PET Center, Yale University School of Medicine. 
 
  Preparation and Use: Describe the method of preparation, storage, stability information, and    
      for parenteral products, method of sterilization and method of testing sterility and pyrogenicity.  
 

 
 
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 [11C]FLB457 is manufactured at the Yale PET center radiochemistry lab. The final product 
solution is passed through a 0.22 uM membrane filter for terminal sterilization to afford a non-
pyrogenic, sterile IV solution ready for injection. The manufacturing procedures quality control 
methods for [11C]FLB457 have been approved by the RDRC. 
 
     
 
   Use of Controlled Substances: 
 
    Will this research project involve the use of controlled substances in human subjects? 
 
    
 Yes  
 No  
(See instructions to view controlled substance listings).  
 
 
    If yes, is the use of the controlled substance considered: 
 
    
 Therapeutic: The use of the controlled substance, within the context of the research, has the  
        potential to benefit the research participant. 
 
    
 Non Therapeutic: Note, the use of a controlled substance in a non therapeutic research  
study involving human subjects may require that the investigator obtain a Laboratory 
Research License. Examples include controlled substances used for basic imaging, observation 
or biochemical studies or other non-therapeutic purposes. See Instructions for further 
information. 
 
Dextro-amphetamine (0.4 mg/kg) will be given by mouth to each subject starting up to 3 hours 
prior to the second [11C]FLB PET scan. 
 
 
 
 
 HUMAN SUBJECTS  
 
1.   Recruitment Procedures: How will potential subjects be identified, contacted and recruited?  
      Upload copies of any recruitment materials that will be used. 
 
Subjects will be recruited through flyers, public advertisement (newspaper, radio, internet 
posting), by word of mouth, contact with community service groups, and clinics and local 
treatment facilities (the VA Hospital, West Haven, CMHC, the Yale Psychiatric Hospital, Mood 
Disorders Research Program, the Yale Depression Research Program).  The subjects will be 
asked to call us if they are interested in participating in the research study.  Interested individuals 
contacting the clinic by phone in response to advertisements are told that the information they 
give over the phone is written down and discussed by the research team.  They are advised that if 
they do not enroll in research with the clinic the information is destroyed, and that if they do, it 
becomes part of their research chart.    If an individual appears to meet enrollment criteria and is 
interested in participating, a face-to-face interview is conducted by one of the project 
investigators.  A release of information is obtained for review of any available historical and 
clinical data.  A written authorization form is also obtained from each subject, permitting the 
research team to use, create, or disclose the subject's PHI for research purposes.  The nature of 
the project, procedures, relative risks and benefits, and alternatives to participation in the project 
are discussed with the individual.  Following this discussion, the individual is given a copy of the 
consent form to review, and any questions are answered. The PI of the protocol will seek written 
consent from all participants. 
 
2.    Subject Population Provide a detailed description of the targeted population of human     

 
 
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       subjects for this research project.  
Tobacco smokers: n = 40 
Healthy nonsmokers: n = 40 
Age range: 18-55 
Gender: Both groups will include an equal proportion of males and females.   
Racial/ethnic group: We will recruit from all ethnic groups available.   
 
3.    Inclusion/Exclusion Criteria: What are the criteria used to determine subject inclusion or   
       exclusion? How will eligibility be determined, and by whom?  
 
The following are the inclusion and exclusion criteria used. Eligibility to participate in screening 
session will be determined by the research staff under the guidance of Dr. Kelly Cosgrove and 
may be screened under HIC# 0808004163 (PI: McKee).  Study participation will be determined 
after the screening session by the study physician and study PI. 
 
General inclusion criteria:  
• men and women, aged 18-55 years 
• who are able to read and write  
• who are able to give voluntary written informed consent 
• have no current uncontrolled  medical condition such as neurological, cardiovascular, 
endocrine, renal, liver, or thyroid pathology  
• have no history of a neurological or psychiatric disorder, e.g., no DSM-IV Axis 1 
diagnosis in 2 preceding years) 
• drink less than 21 drinks/week for women and less than 35 drinks per week for men  
• do not suffer from claustrophobia or any MRI contradictions 
• able to participate in imaging studies including 2 PET scans and 1 MRI scan 
• nonsmokers (smoked < 100 cigarettes in lifetime with urinary cotinine levels 0-30 ng/mL 
both at intake evaluation and on scan day) 
• smokers (smoked at least 10 cigarettes/day for at least one year with an FTND>3, urine 
cotinine >150 ng/mL and CO >12 ppm at intake) 
 
 
General exclusion criteria: 
• psychosis 
• presence of acute or unstable medical or neurological illness. Subjects will be excluded 
from the study if they present with any history of serious medical or neurological illness 
or if they show signs of a major medical or neurological illness on examination or lab 
testing including history of seizures, head injury, brain tumor, heart, liver or kidney 
disease, eating disorder, diabetes. 
• regular use of any psychotropic drugs including anxiolytics and antidepressants and other 
over-the-counter medications and herbal products within the last six months, that in the 
PI’s assessment would put the subject at increased risk or would be detrimental to the 
study data. 
• pregnancy/Breast feeding (as documented by pregnancy testing at screening or at days of 
the imaging studies), 
• suicidal ideation or behavior 
• pacemaker or other ferromagnetic material in body. 
• use of medications which affect dopamine transmission within 2 weeks of the PET study 

 
 
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• Participation in other research studies involving ionizing radiation within one year of the 
PET scans that would cause the subject to exceed the yearly dose limits for normal 
volunteers. 
• Blood donation within 8 weeks of the start of the study. 
• history of a bleeding disorder or are taking medication to thin their blood 
 
Subjects will be asked to abstain from alcohol and marijuana for one week prior to the 
PET scan.  If subjects endorse use within one week of the scan, their continued 
participation will be up to the discretion of the PI. 
 
*  For women of child-bearing age:  The serum pregnancy test is performed during the screening 
procedure and a urine pregnancy test is done on the day of the PET scans prior to imaging.  Since 
this test cannot detect the very early stage of pregnancy (period between fertilization and 
implantation), an effective birth control method or sexual abstinence is required during study 
participation. 
 
 
  
 
CONSENT/ ASSENT PROCEDURES 
 
 
1. Process of Consent/Assent: Describe the setting and conditions under which consent/assent     
     will be obtained, including parental permission or surrogate permission and the steps taken to  
   ensure subjects’ independent decision-making.  
 
Subjects will be given verbal and written information describing the study under conditions in 
which they have adequate time to consider the risks of participation. Each study subject will be 
given a copy of the Consent Form/Compound Authorization Form enclosed with this protocol 
outlining the risks and benefits of participation in this study.   
 
Prior to signing the Compound Authorization Form, the principal investigator or her designee 
(Sub-Investigator/Coordinator, Key Personnel) will discuss the Compound Authorization Form 
with each subject. The prospective subject will be given verbal and written information (the 
Compound Authorization Form) describing Protected Health Information (PHI) and why and to 
whom it will be distributed. The subject will have adequate time to consider this information 
before signing. If the subject decides not to sign the Compound Authorization Form, he/she will 
not be able to participate in the study. A copy of the signed and dated Compound Authorization 
form will be given to each subject and informant. 
 
3.   Evaluation of Subject(s) Capacity to Provide Informed Consent/Assent: Indicate how the  
personnel obtaining consent will assess the potential subject’s ability and capacity to consent to 
the research being proposed.  
 
We will not recruit subjects with limited decision-making capacity. All of the subjects who sign 
the consent to participate in the current protocol or in HIC# 0808004163 (PI: McKee) will have 
completed and met medical (urine and blood tests, EKG, and physical) and psychological (SCID 
and clinical interview). criteria As part of the consent process, prospective subjects are asked 
open-ended questions about the research in order to determine whether the subject recalls and 
understand the process of the study.  If an individual shows poor comprehension of the consent 

 
 
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form and study, we will not enroll them. The screening and enrollment processes are supervised 
by a study doctor. 
 
4.   Documentation of Consent/Assent: Specify the documents that will be used during the  
   consent/assent process. Copies of all documents should be appended to the protocol, in the  
   same format that they will be given to subjects.  
 
Subjects will be given verbal and written information describing the study under conditions in 
which they have adequate time to consider the risks of participation. Each study subject will be 
given a copy of the consent form enclosed with this protocol outlining the risks and benefits of 
participation in this study.   
 
Prior to signing the Compound Authorization Form, the principal investigator or her designee 
(Sub-Investigator/Coordinator, Key Personnel) will discuss the Compound Authorization Form 
with each subject. The prospective subject will be given verbal and written information (the 
Compound Authorization Form) describing Protected Health Information (PHI) and why and to 
whom it will be distributed. The subject will have adequate time to consider this information 
before signing. If the subject decides not to sign the Compound Authorization Form, he/she will 
not be able to participate in the study. A copy of the signed and dated Compound Authorization 
form will be given to each subject and informant. 
 
5.   Non-English Speaking Subjects: Explain provisions in place to ensure comprehension for  
   research involving non-English speaking subjects. Translated copies of all consent materials  
   must be submitted for approval prior to use.  
 
Non-English speaking subjects will not be recruited for this study. 
 
6. Required HIPAA Authorization: If the research involves the creation, use or disclosure of   
protected health information (PHI), separate subject authorization is required under the 
HIPAA Privacy Rule. Indicate which of the following forms are being provided: 
 
  
 Compound Consent and Authorization form 
 
  
 HIPAA Research Authorization Form 
 
  
 
 
SECTION VI: PROTECTION OF RESEARCH SUBJECTS 
 
 
1.   Risks: Describe the reasonably foreseeable risks, including risks to subject privacy,  
     discomforts, or inconveniences associated with subjects’ participation in the research.  
 
a.  Risks of  [11C]FLB457  
The Yale-New Haven Hospital Radiation Safety Committee (RSC) will review the use of 
radiation in this research study, and no subjects will be enrolled until RSC approval is obtained. 
This research study involves exposure to radiation from [11C]FLB457 PET scanning. This 
radiation exposure is not necessary for medical care and is for research purposes only. The total 
amount of radiation an individual subject will receive in this study is from up to 4 injection(s) 
with a total of ≤ 10 mCi (per injection) from [11C]FLB457, plus transmission scans of the brain. 
  

 
 
Page 13 
 
 
Although each organ will receive a different dose, the maximum amount of radiation exposure 
subjects will receive from this study is equal to an effective dose of 1.24 rem for a total of up to 
40 mCi of [11C]FLB457  in 4 injections (10 mCi per injection). That is, a total of 1.24 rem for 4 
scan(s) is the amount of radiation exposure that a subject will receive from the study.  This 
calculated value is used to relate the dose received by each organ to a single value. 
  
The amount of radiation subjects will receive in this study is below the dose guidelines established 
by the FDA and monitored by the Yale-New Haven Hospital Radiation Safety Committee for 
research subjects. This guideline sets an effective dose limit of 5 rem per year. 
 
c.  Risks of oral d-amphetamine  
Risks of amphetamine administration include both medical and psychiatric risks. 
 
The frequent somatic side effects of d-amphetamine administration are cardiovascular 
(hypertension, palpitations, tachycardia, bradycardia, orthostasis). General effects such as 
sweating, feeling warm or cold, nausea, diarrhea, muscle and abdominal cramping,have been 
reported frequently. Behavioral effects in this dose range are increased level of alertness, 
talkativeness, restlessness, agitation, mood changes (usually euphoria) and anxiety. In our 
experience, these effects are generally transient and well tolerated. This dose of amphetamine 
has not been reported to induce psychotic symptoms in non-schizophrenic subjects. Infrequently 
blurred vision, headaches and chest tightness, and changes in EKG have been reported. There is 
a rare risk of permanent neurological damage and death as a result of cardiac arrest or stroke. 
 
Psychiatric or behavioral side effects:  General behavioral effects of the injection of 
amphetamine in this dose range are increased level of alertness, talkativeness, restlessness, 
agitation, mood changes (usually euphoria) and anxiety.  In our experience, these effects are 
generally transient and well tolerated.  This dose of amphetamine has not been reported to induce 
psychotic symptoms in non schizophrenic subjects and we confirm this observation.  
 
c. Risks of placing an intra-arterial catheter 
On the PET scan day a radial arterial catheter will be inserted. Arterial sampling may be associated 
with mild-to-moderate pain or bruising at the puncture site. In rare instances blocking of the artery, 
poor healing, hematoma, inflammation, or infection at the catheter insertion site may occur. 
Certain individuals may feel light-headed during arterial catheter placement. 
 
d. Risks of placing an intra-venous catheter  
Drawing blood and inserting an intravenous line (IV) into an arm vein are safe and standard 
medical procedures. Sometimes a bruise will occur at the puncture site and rarely a blood clot or 
infection will occur in the vein. Certain individuals may feel light-headed during venipuncture. 
The volume of blood collected during this study, include screening laboratories, will be 
approximately 19 tablespoons. This is not expected to have any serious negative effects on a study 
participant.  
 
e. Risks of an MRI scan  
MR carries a risk for subjects who are claustrophobia or have pacemakers, metal pieces, 
aneurysm clips, large colored tattoos, or any other contraindications for MR. Magnetic resonance 
(MR) is a technique that uses magnetism and radio waves, not x-rays, to take pictures and 
measure chemicals of various parts of the body. The United States Food and Drug 

 
 
Page 14 
 
 
Administration (FDA) has set guidelines for magnet strength and exposure to radio waves, and 
we carefully observe those guidelines. 
 
Subjects will be watched closely throughout the MR study. Some people may feel uncomfortable 
or anxious. If this happens, the subject may ask to stop the study at any time and we will take 
them out of the MR scanner. On rare occasions, some people might feel dizzy, get an upset 
stomach, have a metallic taste or feel tingling sensations or muscle twitches. These sensations 
usually go away quickly but we will ask subjects to tell the research staff if they have them. 
There are some risks with an MR study for certain people. If subjects have a pacemaker or some 
metal objects inside their body, they may not be in this study because the strong magnets in the 
MR scanner might harm them. Another risk is the possibility of metal objects being pulled into 
the magnet and hitting a subject. To reduce this risk we require that all people involved with the 
study remove all metal from their clothing and all metal objects from their pockets. We also ask 
all people involved with the study to walk through a detector designed to detect metal objects. It 
is important to know that no metal can be brought into the magnet room at any time. Also, once 
subjects are in the magnet, the door to the room will be closed so that no one from outside 
accidentally goes near the magnet. 
 
We want subjects to read and answer very carefully the questions on the MR Safety 
Questionnaire related to their personal safety. We will be sure that subjects have read the MR 
Safety Questionnaire and tell us any information they think might be important. 
 
 
2.   Minimizing Risks: Describe the manner in which the above-mentioned risks will be   
      minimized.  
 
a. For risks associated with [11C]FLB457  
The dose of radiation will be submitted for approval to the Yale-New Haven Hospital Radiation 
Safety Committee (Y-NHH RSC). All scans will be done in the presence of medical supervision 
and trained nursing staff in an institution specifically designed to support imaging studies. In the 
event of serious medical complications, the PET scan facilities have immediate access to or 
consultation with specialized medical units at the Yale-New Haven Hospital Preparation of 
radiopharmaceuticals and performance of PET scans will be by radiochemists, physicians, and 
technologists of the Department of Diagnostic Radiology, Yale University School of Medicine. 
These professionals are qualified by training and experience in the safe use and handling of 
radiopharmaceuticals. Subjects will be asked about their previous radiation exposure and those 
who have had research exposure within the past year will be excluded if their cumulative annual 
exposure (including the present study) exceeds FDA limits.   The information on the previous 
radiation exposure of study subjects will be notified to the study doctor.  No PET studies will be 
performed on pregnant or potentially pregnant women, as confirmed by pregnancy testing during 
evaluation and on each scan day before initiation of any scan procedures. If subjects are 
breastfeeding they will not be able to participate in this research study.  
 
b. For risks associated with oral d-amphetamine administration 
Medical side effects: Subjects will be screened for absence of significant medical history and 
current medical conditions with a complete medical history, physical examination, routine blood 
tests, urine toxicology and EKG. The study will be canceled on the day of the scan if several of 
the subject’s blood pressure readings are recorded at >90 for diastolic BP or >140 for systolic BP 
while at rest. Any automated blood pressure results that are abnormal will be repeated manually. 

 
 
Page 15 
 
 
The manual reading will be the official reading.  
Inclusion in the study will be limited to individuals who are between the ages of 18-55. 
Patients will be excluded if they have any h/o severe medical or neurological illness, any 
clinically significant brain abnormality, low Hgb, insulin dependent diabetes, more than one risk 
factor for coronary artery disease , a history of cardiovascular disease, or hypertension. 
Patients will be excluded if they have recently donated blood. 
Administration of oral d-amphetamine will take place at the PET center with a physician on site. 
Constant EKG and frequent BP monitoring will occur until the vital signs are within normal 
limits. If the systolic BP reaches or exceeds 200 mmHg for more than 5 minutes, an infusion of 
phentolamine (5 mg IV, over 10 min) will be initiated to control the blood pressure response.  
The study physician will be notified if those parameters are reached and he/she will supervise the 
treatment.   
A twelve lead EKG, a code cart and defibrillator are available in the room in case of 
complications. In case of chest pain, chest tightness or other symptoms suggestive of cardiac 
ischemia, the experiment will be cancelled and a twelve lead EKG will be immediately obtained 
to rule out angina (ST segment elevation or depression as compared to the baseline EKG). 
Appropriate treatment will be initiated. 
Upon discharge, patients will be given the phone numbers of the study physicians from the 
Division of Translational Imaging and will follow up at least weekly with the study physician, 
with in-person sessions in each of the first two weeks after amphetamine administration. 
 
Psychiatric/behavioral side effects: Inclusion in the study will be limited to individuals who are 
between the ages of 18-55. No individuals with psychiatric disorders will be recruited into this 
protocol, on or off of medications. All subjects will receive a follow up all 30 days after 
receiving amphetamine to check that they are feeling well and do not still have effects from the 
amphetamine challenge. 
 
c. For risks associated with placing an intra-arterial catheter 
Risks of radial artery cannulation are minimized by having the procedure performed by an 
experienced physician. Pain is minimized by local anesthesia. Bleeding is prevented by local 
pressure applied for a minimum of 15 minutes after catheter removal. Subjects will have their 
hand and finger blood supply examined after arterial cannulation and again following catheter 
removal. Also, subjects will be asked to abstain from using aspirin, NSAIDS or anticoagulants. 
Subjects will be provided a 24 hour emergency physician telephone number to call if they 
encounter pain, discoloration, numbness, tingling, coolness, hematoma, inflammation, or any 
other unusual symptoms in the wrist or hand, or fever, chills or drainage from the vascular 
puncture sites, following the procedure. Nurses will provide the subjects an instruction sheet 
documenting problems to watch for and procedures to follow should such problems occur. 
Infection is avoided by adequate cleansing of the skin prior to intravascular line insertion. 
 
d. For risks associated with placing an intravenous catheter 
The risks of bruising, clotting, and infection will be minimized by having venipuncture performed 
by trained and experienced personnel under sterile conditions. To avoid injury due to fainting, the 
antecubital vein catheter will be inserted when the subjects are recumbent. The blood draws during 
PET scanning sessions will be obtained from the already inserted catheter, to minimize discomfort. 
 
e. For risks associated with the MRI 
To minimize risks, each subject will fill out the MRI Safety Questionnaire before the study. Only 
subjects who fulfill the criteria by this questionnaire will be eligible for the study. In addition, 

 
 
Page 16 
 
 
subjects will remove all metal (watch, hair pins, jewelry). Before entering the MRI room. If the 
subject has any metallic prostheses/implants they will be excluded from the study. If a subject 
becomes anxious during the scan they can request that the MRI scan be stopped. 
 
3.    Data and Safety Monitoring Plan:  
 
  
1.Personnel responsible for safety review and its frequency: 
The principal investigator in collaboration with David Matuskey, MD will be responsible for 
monitoring the data, assuring protocol compliance, and conducting the safety reviews at the 
specified frequency. During the review process, the principal investigator (monitor) will evaluate 
whether the study should continue unchanged, require modification/amendment, continue or 
close to enrollment. Either the principal investigator, the HIC, the FDA, or the RDRC, have the 
authority to stop or suspend the study or require modifications. 
 
2. The risks associated with the current study are deemed moderate for the following 
reasons: 
 
We view the risks associated with radiation exposure, amphetamine administration, and arterial 
line placement as moderate. 
 
 
Although we have assessed the proposed study as one of moderate risk, the potential exists for 
anticipated and/or unanticipated adverse events, serious or otherwise, to occur since it is not 
possible to predict with certainty the absolute risk in any given individual or in advance of first-
hand experience with the proposed study methods.  Therefore, we provide a plan for monitoring 
the data and safety of the proposed study as follows: 
 
 
3. Attribution of Adverse Events:  
Adverse events will be monitored for each subject participating in the study and attributed to the 
study procedures / design by the principal investigator, Kelly Cosgrove, PhD, according to the 
following categories:  
  
a.) Definite: Adverse event is clearly related to investigational procedures(s)/agent(s).  
b.) Probable: Adverse event is likely related to investigational procedures(s)/agent(s).  
c.) Possible: Adverse event may be related to investigational procedures(s)/agent(s).  
d.) Unlikely: Adverse event is likely not to be related to the investigational 
procedures(s)/agent(s).  
e.) Unrelated: Adverse event is clearly not related to investigational procedures(s)/agent(s). 
 
4.  Plan for Grading Adverse Events: 
The following scale will be used in grading the severity of adverse events noted during  
the study:  
  
a. Mild adverse event  
b. Moderate adverse event  
c. Severe   
  
5. Plan for Determining Seriousness of Adverse Events:  
 
Serious Adverse Events:  
In addition to grading the adverse event, the PI will determine whether the adverse event meets 

 
 
Page 17 
 
 
the criteria for a Serious Adverse Event (SAE).  An adverse event is considered serious if it:  
  
1. is life-threatening  
2. results in in-patient hospitalization or prolongation of existing hospitalization  
3. results in persistent or significant disability or incapacity   
4. results in a congenital anomaly or birth defect OR  
5. results in death  
6. based upon appropriate medical judgment, may jeopardize the subject’s health and may 
require medical or surgical intervention to prevent one of the other outcomes listed in this 
definition, or  
7. adversly affects the risk/benefit ratio of the study  
  
An adverse event may be graded as severe but still not meet the criteria for a Serious Adverse 
Event.  Similarly, an adverse event may be graded as moderate but still meet the criteria for an 
SAE.  It is important for the PI to consider the grade of the event as well as its “seriousness” 
when determining whether reporting to the HIC is necessary.  
  
6. Plan for reporting serious AND unanticipated AND related adverse events, anticipated 
adverse events occurring at a greater frequency than expected, and other unanticipated 
problems involving risks to subjects or others to the HIC.  
  
The investigator will report the following types of adverse events to the HIC or HSC: a) serious 
AND unanticipated AND possibly, probably or definitely related events; b) anticipated adverse 
events occurring with a greater frequency than expected; and c) other unanticipated problems 
involving risks to subjects or others.  
  
These adverse events or unanticipated problems involving risks to subjects or others will be 
reported to the HIC within 48 hours of it becoming known to the investigator, using the 
appropriate forms found on the website.  
  
7. Plan for reporting adverse events: 
  
For the current study, the following individuals, funding, and/or regulatory agencies will be 
notified (choose those that apply):  
 X All Co-Investigators listed on the protocol  
X National Institutes of Health  
X   Yale New-Haven Hospital Radiation Safety Committee (RSC/RDRC) 
  
The principal investigator, Kelly Cosgrove, PhD, in collaboration with David Matuskey, MD 
will conduct a review of all adverse events upon completion of every study subject. The principal 
investigator will evaluate the frequency and severity of the adverse events and determine if 
modifications to the protocol or consent form are required. 
 
4.   Confidentiality & Security of Data: 
Required private identifiable information about individuals, such as their medical history, 
current medications, psychiatric problems, and family history, will be collected by research 
staff and be used for research purposes and charting after consent is obtained. 

 
 
Page 18 
 
 
 
Yale PET Center staff will collect required research data through study procedures as 
outlined in this protocol, and record it in confidential research records and protected 
computer files. 
 
Identifiable information is kept in locked file drawers and password protected computer 
files. Results are published as group data without the use of characteristics that would 
identify individual subjects. We quote information only by number in conference 
discussions, scientific reports, or publications, in order to maintain anonymity. 
Identifiable research data, including recruitment and screening information and code keys, 
are stored on a secure database located on the internal PET Center Network.  The PET 
network is protected by a Cisco PIX firewall operated by ITS.  All research data are backed 
up nightly to a Dell PV-136T library wit 4 IBM Ultrium-TD2 tape drives using the backup 
software Legato Networker 7.3 from EMC.  Human subjects enrolled in the study are 
assigned a subject-specific random identifier.  Subject identifiers and the means to link the 
subject names and codes with the research data are stored in separate locations within the 
database.  The software of the database limits the ability to connect the random identifier 
to the actual subject identification information to research team members only.  Access to 
the database is password protected and each research team member is required to have a 
unique ID and password to gain access to the database.  Authorized users employ their 
netid and authentication is performed using Yale’s central authentication server.  Users 
always access research data through the random identifier only. 
At the VACHS, we will use coded records and keep signed consent forms in a locked 
cabinet. Forms that contain the subjects' names and identifying information will be stored 
in the medical chart in a locked file. Electronic data is stored in a password-protected 
database at the VACHS. Access to this database is limited to investigators and research 
staff within the PIs laboratory.  
Their MRI report is transferred to the Yale PET Center and kept on their secure 
servers described above.  
 
Procedures to ensure confidentiality follow the regulations and policies of the Yale 
University School of Medicine.  The security mechanisms specified above in 4d will 
continue to be in place to protect study data. 
 
Investigators and research staff at Yale University School of Medicine, VACHS, Yale 
University Human Investigation Committee (HIC), the FDA, and NIH may have access to 
the protected health information. 
 
In the event of relevant discovery related to events of abuse, identified health risks, or 
threats to self or others, as related to the health and safety of the public and/or individual 
study participants, a report will be made to the relevant agencies and authorities to be 
conducted as outlined and mandated by HIC guidelines, and Federal, State, and Local 
Statutes. 
 
5.   Potential Benefits: Identify any benefits that may be reasonably expected to result from the  
research, either to the subject(s) or to society at large. (Note: Payment of subjects is not 
considered a benefit in this context of the risk-benefit assessment.)  
 

 
 
Page 19 
 
 
There are no direct benefits from a subject's participation in this study. This research will 
benefit scientific knowledge by contributing to the understanding of the role of sex differences 
and dopamine in tobacco smoking addiction.  Society may benefit from these insights, as they 
may have clinical application in the future. 
 
         RESEARCH ALTERNATIVES AND ECONOMIC CONSIDERATIONS 
 
       1.   Alternatives: What alternatives are available to the study subjects outside of the 
              research? 
 
The alternative to participation in this study is to decline participation. 
       2.   Payments for Participation (Economic Considerations): Describe any payments that will 
             be made to subjects and the conditions for receiving this compensation.  
 
The subjects will be compensated for their time commitment and inconveniences necessary for 
completing the study. Subjects will have no financial responsibilities for any portion of the study. 
Compensation will be up to $50 for each MRI scan, $350 for each PET scan, and $50 for each 
arterial line.  In addition, smoker subjects from Aim 3 will be given a $100 bonus for completing 
all portions of the study.  Subjects who participate in the Probabilistic Reward Task may also be 
compensated for the amount that they “win” during the task, up to $50.   Subjects may be 
provided with payment in a form of a pre paid credit card, cash or a check.  In addition, subjects 
will be provided with a light lunch.  They will also be reimbursed for parking on study visit days 
or they will be compensated for reasonable transportation costs. If participation in the PET Scan 
has already begun, then compensation to will be based on involvement in the study, and will be 
up to the discretion of the PI. In addition, subjects participating in Aim 3 will be paid $20 for the 
script development session.  Subjects will be paid either by check, and are advised to allow 4-6 
weeks for receipt of payment, or they will be given a pre paid credit card, or cash.  Subjects may 
be compensated for parking for research study appointments. They must show their parking 
ticket to the Research Staff for verification. Parking tickets will be returned to the subject so they 
are able to exit the parking lots and they will sign a Parking Voucher for the money received. 
 
Cancellations:  If a PET scan should get cancelled for a reason outside of the subject's control 
(i.e. radiotracer synthesis failure) the subject will be paid $50 minimum, or a higher amount not 
to exceed the payment for a full scan day.  The amount of the payment for cancellation will be 
based on the subject's length of participation on that scan day prior to the cancellation, and will 
be up to the discretion of the PI. 
 
       3.   Costs for Participation (Economic Considerations): Clearly describe the subject’s costs 
             associated with participation in the research, and the interventions or procedures of the study 
             that will be provided at no cost to subjects.      
There is no cost to subjects for any of the research procedures.  
   
 
4.   In Case of Injury: This section is required for any research involving more than minimal  
 
      risk. 
a. 
Will medical treatment be available if research-related injury occurs?  
Yes  
b. 
Where and from whom may treatment be obtained?  

 
 
Page 20 
 
 
Treatment may be provided by Yale-New Haven Hospital, or any health care 
provider chosen by the study subjects. 
c. 
Are there any limits to the treatment being provided?  
Only emergency care will be provided. Limits to treatment may be imposed by the 
insurance carrier of the study subjects. 
d. 
Who will pay for this treatment?  
The study participant or his insurance carrier will be expected to pay the costs of this 
treatment. 
No additional financial compensation for injury or lost wages is available. The cost 
of treatment will be borne by the subject or their insurance carrier. 
e. 
How will the medical treatment be accessed by subjects?  
The study team will provide assistance to the study subjects in accessing medical 
treatment through referrals, or the study subjects may choose to access treatment on 
their own.  

 
 
Page 21 
 
 
References 
 
1. 
Benowitz NL. Pharmacology of nicotine: addiction, smoking-induced disease, and 
therapeutics. Annu Rev Pharmacol Toxicol. 2009;49:57-71. 
2. 
Di Chiara G, Imperato A. Drugs abused by humans preferentially increase synaptic 
dopamine concentrations in the mesolimbic system of freely moving rats. Proceedings of the 
National Academy of Sciences of the United States of America. 1988;85(14):5274-8. 
3. 
Dewey SL, Brodie JD, Gerasimov M, Horan B, Gardner EL, Ashby CR, Jr. A 
pharmacologic strategy for the treatment of nicotine addiction. Synapse. 1999;31(1):76-86. 
4. 
Brazell MP, Mitchell SN, Joseph MH, Gray JA. Acute administration of nicotine 
increases the in vivo extracellular levels of dopamine, 3,4-dihydroxyphenylacetic acid and 
ascorbic acid preferentially in the nucleus accumbens of the rat: comparison with caudate-
putamen. Neuropharmacology. 1990;29(12):1177-85. 
5. 
Imperato A, Mulas A, DiChiara G. Nicotine preferentially stimulates dopamine release in 
the limbic system of freely moving rats. Eur J Pharmacol. 1986;132:337-8. 
6. 
Gerasimov MR, Franceschi M, Volkow ND, Rice O, Schiffer WK, Dewey SL. 
Synergistic interactions between nicotine and cocaine or methylphenidate depend on the dose of 
dopamine transporter inhibitor. Synapse. 2000;38(4):432-7. 
7. 
Marenco S, Carson RE, Berman KF, Herscovitch P, Weinberger DR. Nicotine-induced 
dopamine release in primates measured with [11C]raclopride PET. Neuropsychopharmacology : 
official publication of the American College of Neuropsychopharmacology. 2004;29(2):259-68. 
8. 
Cumming P, Rosa-Neto P, Watanabe H, Smith D, Bender D, Clarke PB, et al. Effects of 
acute nicotine on hemodynamics and binding of [11C]raclopride to dopamine D2,3 receptors in 
pig brain. Neuroimage. 2003;19(3):1127-36. 
9. 
Tsukada H, Miyasato K, Kakiuchi T, Nishiyama S, Harada N, Domino EF. Comparative 
effects of methamphetamine and nicotine on the striatal [(11)C]raclopride binding in 
unanesthetized monkeys. Synapse. 2002;45(4):207-12. 
10. 
Brody AL, Olmstead RE, London ED, Farahi J, Meyer JH, Grossman P, et al. Smoking-
induced ventral striatum dopamine release. The American journal of psychiatry. 
2004;161(7):1211-8. 
11. 
Scott DJ, Domino EF, Heitzeg MM, Koeppe RA, Ni L, Guthrie S, et al. Smoking 
modulation of mu-opioid and dopamine D2 receptor-mediated neurotransmission in humans. 
Neuropsychopharmacology : official publication of the American College of 
Neuropsychopharmacology. 2007;32(2):450-7. 
12. 
Barrett SP, Boileau I, Okker J, Pihl RO, Dagher A. The hedonic response to cigarette 
smoking is proportional to dopamine release in the human striatum as measured by positron 
emission tomography and [11C]raclopride. Synapse. 2004;54(2):65-71. 
13. 
Talhout R, Opperhuizen A, van Amsterdam JG. Role of acetaldehyde in tobacco smoke 
addiction. Eur Neuropsychopharmacol. 2007;17(10):627-36. 
14. 
Villegier AS, Lotfipour S, McQuown SC, Belluzzi JD, Leslie FM. Tranylcypromine 
enhancement of nicotine self-administration. Neuropharmacology. 2007;52(6):1415-25. 
15. 
Takahashi H, Fujimura Y, Hayashi M, Takano H, Kato M, Okubo Y, et al. Enhanced 
dopamine release by nicotine in cigarette smokers: a double-blind, randomized, placebo-
controlled pilot study. Int J Neuropsychopharmacol. 2007:1-5. 
16. 
Montgomery AJ, Lingford-Hughes AR, Egerton A, Nutt DJ, Grasby PM. The effect of 
nicotine on striatal dopamine release in man: A [11C]raclopride PET study. Synapse. 
2007;61(8):637-45. 

 
 
Page 22 
 
 
17. 
Marshall DL, Redfern PH, Wonnacott S. Presynaptic nicotinic modulation of dopamine 
release in the three ascending pathways studied by in vivo microdialysis: comparison of naive 
and chronic nicotine-treated rats. Journal of neurochemistry. 1997;68(4):1511-9. 
18. 
Shim I, Javaid JI, Wirtshafter D, Jang SY, Shin KH, Lee HJ, et al. Nicotine-induced 
behavioral sensitization is associated with extracellular dopamine release and expression of c-
Fos in the striatum and nucleus accumbens of the rat. Behavioural brain research. 2001;121(1-
2):137-47. 
19. 
Abi-Dargham A, Gil R, Krystal J, Baldwin RM, Seibyl JP, Bowers M, et al. Increased 
striatal dopamine transmission in schizophrenia: confirmation in a second cohort. The American 
journal of psychiatry. 1998;155(6):761-7. 
20. 
Cardenas L, Houle S, Kapur S, Busto UE. Oral D-amphetamine causes prolonged 
displacement of [11C]raclopride as measured by PET. Synapse. 2004;51(1):27-31. 
21. 
Dewey SL, Smith GS, Logan J, Brodie JD, Fowler JS, Wolf AP. Striatal binding of the 
PET ligand 11C-raclopride is altered by drugs that modify synaptic dopamine levels. Synapse. 
1993;13(4):350-6. 
22. 
Laruelle M. Imaging synaptic neurotransmission with in vivo binding competition 
techniques: a critical review. Journal of cerebral blood flow and metabolism : official journal of 
the International Society of Cerebral Blood Flow and Metabolism. 2000;20(3):423-51. 
23. 
Martinez D, Slifstein M, Broft A, Mawlawi O, Hwang DR, Huang Y, et al. Imaging 
human mesolimbic dopamine transmission with positron emission tomography. Part II: 
amphetamine-induced dopamine release in the functional subdivisions of the striatum. Journal of 
cerebral blood flow and metabolism : official journal of the International Society of Cerebral 
Blood Flow and Metabolism. 2003;23(3):285-300. 
24. 
Riccardi P, Zald D, Li R, Park S, Ansari MS, Dawant B, et al. Sex differences in 
amphetamine-induced displacement of [(18)F]fallypride in striatal and extrastriatal regions: a 
PET study. The American journal of psychiatry. 2006;163(9):1639-41. 
25. 
Munro CA, McCaul ME, Wong DF, Oswald LM, Zhou Y, Brasic J, et al. Sex differences 
in striatal dopamine release in healthy adults. Biological psychiatry. 2006;59(10):966-74. 
26. 
Sun W, Ginovart N, Ko F, Seeman P, Kapur S. In vivo evidence for dopamine-mediated 
internalization of D2-receptors after amphetamine: differential findings with [3H]raclopride 
versus [3H]spiperone. Molecular pharmacology. 2003;63(2):456-62. 
27. 
Narendran R, Frankle WG, Mason NS, Rabiner EA, Gunn RN, Searle GE, et al. Positron 
emission tomography imaging of amphetamine-induced dopamine release in the human cortex: a 
comparative evaluation of the high affinity dopamine D2/3 radiotracers [11C]FLB 457 and 
[11C]fallypride. Synapse. 2009;63(6):447-61. 
28. 
Narendran R, Mason NS, May MA, Chen CM, Kendro S, Ridler K, et al. Positron 
emission tomography imaging of dopamine D/ receptors in the human cortex with [(1)(1)C]FLB 
457: reproducibility studies. Synapse. 2011;65(1):35-40. 
29. 
Chou YH, Halldin C, Farde L. Effect of amphetamine on extrastriatal D2 dopamine 
receptor binding in the primate brain: a PET study. Synapse. 2000;38(2):138-43. 
30. 
Perkins KA, Scott J. Sex differences in long-term smoking cessation rates due to nicotine 
patch. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and 
Tobacco. 2008;10(7):1245-50. 
31. 
Bjornson W, Rand C, Connett JE, Lindgren P, Nides M, Pope F, et al. Gender differences 
in smoking cessation after 3 years in the Lung Health Study. Am J Public Health. 
1995;85(2):223-30. 
32. 
Wetter D, Kenford S, Smith S, Fiore M, Jorenby D, Baker T. Gender differences in 
smoking cessation. Journal of Consulting and Clinical Psychology. 1999;67:555-62. 

 
 
Page 23 
 
 
33. 
Osler M, Prescott E, Godtfredsen N, Hein H, Schnohr P. Gender and determinants of 
smoking cessation: a longitudinal study. Prev Med. 1999;29:57-62. 
34. 
Sherman SE, Fu SS, Joseph AM, Lanto AB, Yano EM. Gender differences in smoking 
cessation services received among veterans. Womens Health Issues. 2005;15(3):126-33. 
35. 
Piper ME, Cook JW, Schlam TR, Jorenby DE, Smith SS, Bolt DM, et al. Gender, race, 
and education differences in abstinence rates among participants in two randomized smoking 
cessation trials. Nicotine & tobacco research : official journal of the Society for Research on 
Nicotine and Tobacco.12(6):647-57. 
36. 
Perkins K. Nicotine discrimination in men and women. Pharmacology Biochemistry and 
Behavior. 1999;64:295-9. 
37. 
McBride D, Barrett SP, Kelly JT, Aw A, Dagher A. Effects of expectancy and abstinence 
on the neural response to smoking cues in cigarette smokers: an fMRI study. 
Neuropsychopharmacology : official publication of the American College of 
Neuropsychopharmacology. 2006;31(12):2728-38. 
38. 
Perkins K, Donny E, Caggiula A. Sex differences in nicotine effects and self-
administration: Review of human and animal evidence. Nicotine & Tobacco Research. 
1999;1:301-15. 
39. 
Kaasinen V, Nagren K, Hietala J, Farde L, Rinne JO. Sex differences in extrastriatal 
dopamine d(2)-like receptors in the human brain. The American journal of psychiatry. 
2001;158(2):308-11. 
40. 
Laakso A, Vilkman H, Bergman J, Haaparanta M, Solin O, Syvalahti E, et al. Sex 
differences in striatal presynaptic dopamine synthesis capacity in healthy subjects. Biological 
psychiatry. 2002;52(7):759-63. 
41. 
Spitzer R, Williams J, Gibbon M, First M. The Structured Clinical Interview for DSM-
III-R (SCID). I: History, rationale, and description. Archives of general psychiatry. 1992;49:624-
9. 
42. 
Radloff L. The CES-D scale: A self-report depression scale for research in the general 
population. Applied Psychol Meas. 1977;1:385-401. 
43. 
Weissman M, Sholomskas D, Potenger M, Prusoff B, Locke B. Assessing depressive 
symptoms in psychiatric populations: a validation study. Am J Epidemiology. 1977;106:203-14. 
44. 
Kinnunen T, Doherty K, Militello F, Garvey A. Depression and smoking cessation: 
Characteristics of depressed smokers and effects of nicotine replacement. J Consult Clin Psychol. 
1996;64:791-8. 
45. 
Spielberger C, Corsuch R, Jushene R, al. e, editors. Manual for State-Trait Anxiety 
Inventory. Palo Alto CA: Consulting Psychologists Press; 1983. 
46. 
Patton JH, Stanford MS, Barratt ES. Factor structure of the Barratt impulsiveness scale. J 
Clin Psychol. 1995;51(6):768-74. 
47. 
Heatherton T, Kozlowski L, Frecker R, Fagerstrom K. The Fagerstrom test for nicotine 
dependence: a revision of the Fagerstrom tolerance questionairre. Brit J Addiction. 
1991;86:1467-76. 
48. 
Hughes J, Hatsukami D. Signs and symptoms of tobacco withdrawal. Arch Gen 
Psychiatry. 1986;43:289-94. 
49. 
Tiffany S, Drobes D. The development and initial validation of a questionnaire on 
smoking urges. British Journal of Addictions. 1991;86:1467-76. 
50. 
Pizzagalli DA, Jahn AL, O'Shea JP. Toward an objective characterization of an 
anhedonic phenotype: a signal-detection approach. Biological psychiatry. 2005;57(4):319-27. 
51. 
Pizzagalli DA, Iosifescu DV, Hallett LA, Ratner KG, Fava M. Reduced hedonic capacity 
in major depressive disorder: evidence from a probabilistic reward task. J Psychiatr Res. 
2008;43(1):76-87. 

 
 
Page 24 
 
 
52. 
Pizzagalli DA, Goetz E, Ostacher M, Iosifescu DV, Perlis RH. Euthymic patients with 
bipolar disorder show decreased reward learning in a probabilistic reward task. Biological 
psychiatry. 2008;64(2):162-8. 
53. 
Cheng Y, Prusoff W. Mouse ascites sarcoma 180 thymidylate kinase. General properties, 
kinetic analysis, and inhibition studies. Biochemistry. 1973;12(14):2612-9. 
54. 
Kapur S, Barsoum S, Seeman P. Dopamine D(2) receptor blockade by haloperidol. (3)H-
raclopride reveals much higher occupancy than EEDQ. Neuropsychopharmacology. 
2000;23(5):595-8. 
55. 
Seeman P, Ulpian C. Dopamine D1 and D2 receptor selectivities of agonists and 
antagonists. Adv Exp Med Biol. 1988;235:55-63. 
56. 
Malmberg A, Nordvall G, Johansson A, Mohell N, Hacksell U. Molecular basis for the 
binding of 2-aminotetralins to human dopamine D2A and D3 receptors. Mol Pharmacol. 
1994;46:299-312. 
57. 
Seeman P. Antipsychotic drugs, dopamine receptors, and schizophrenia. . Clin Neurosci 
Res. 2001;1:53-60. 
58. 
Graff-Guerrero A, Willeit M, Ginovart N, Mamo D, Mizrahi R, Rusjan P, et al. Brain 
region binding of the D2/3 agonist [11C]-(+)-PHNO and the D2/3 antagonist [11C]raclopride in 
healthy humans. Hum Brain Mapp. 2007;29(4):400-10. 
59. 
Buckholtz JW, Treadway MT, Cowan RL, Woodward ND, Li R, Ansari MS, et al. 
Dopaminergic network differences in human impulsivity. Science.329(5991):532. 
60. 
Aalto S, Hirvonen J, Kaasinen V, Hagelberg N, Kajander J, Nagren K, et al. The effects 
of d-amphetamine on extrastriatal dopamine D2/D3 receptors: a randomized, double-blind, 
placebo-controlled PET study with [11C]FLB 457 in healthy subjects. European journal of 
nuclear medicine and molecular imaging. 2009;36(3):475-83. 
61. 
Martinez D, Gil R, Slifstein M, Hwang DR, Huang Y, Perez A, et al. Alcohol dependence 
is associated with blunted dopamine transmission in the ventral striatum. Biological psychiatry. 
2005;58(10):779-86.