Feasibility of PET/CT to Detect the Oral/Pulmonary Distribution of Nicotine Following E-cigarette Use
Phase: PHASE4
Conditions: E-cigarette Use
Sponsor: University of Cincinnati

THE OHIO STATE UNIVERSITY 
 
Institutional Review Board 
Version: December 20, 2017 
Page 1 of 16 
Protocol Title 
Feasibility of PET/CT to detect the oral/pulmonary distribution of 
nicotine following e-cigarette use 
 
Protocol Project Number 
SP0232 
Protocol Date 
December 20, 2017 
 
Principal Investigator 
Michael V. Knopp, MD, PhD  
Novartis Chair of Imaging Research  
Vice Chairman and Professor,  
 
Department of Radiology 
 
The Ohio State University  
 
395 West 12th Avenue, Room 430 
 
Columbus, Ohio 43210 
 
Phone:  
(614) 293-9998 
 
Fax: 
 
(614) 293-9275 
 
E-Mail: 
knopp.16@osu.edu 
 
 

THE OHIO STATE UNIVERSITY 
 
Institutional Review Board 
Version: December 20, 2017 
Page 2 of 16 
OBJECTIVES 
Aim 1: To establish the methodology required for the evaluation of the biodistribution (in vivo 
deposition, absorption and transport) of carbon 11 (11C) labeled nicotine following e-cigarette use 
Aim 2: To determine the cranio-pharyngeal/pulmonary distribution of nicotine following e-
cigarette use 
Aim 3: To determine the potentially lowest required dose using the next generation digital PET/CT 
technology to provide detailed or accurate oral/pulmonary distribution data following e-cigarette 
use  
BACKGROUND AND RATIONALE 
Electronic cigarettes (e-cigarettes) are marketed as non-combustible nicotine delivery devices. 
Typically, the device works by the user placing a refill cartridge/solution (containing carrier 
solvents and nicotine) into the device. An airflow sensor or power button is then used to activate 
a battery that turns on an atomizer. The atomizer then produces an aerosol from the liquid 
containing the nicotine. This aerosol is typically, but inaccurately, referred to as a vapor, so the 
term vaporizer is commonly used to describe the device. It must be noted; however, that since fine 
particulates (solid, liquid, and gas) are formed, the atomization of the solvent results in an aerosol 
and not a vapor. This aerosol simulates cigarette smoke in that the aerosol is delivered into the 
mouth and respiratory tree by inhalation. The remaining (non-absorbed) aerosol is then exhaled. 
E-cigarette manufacturers claim that e-cigarettes are safer than conventional cigarettes and that 
they may aid in smoking cessation. As a result, e-cigarettes are gaining popularity and use in the 
general public as a replacement for traditional cigarettes. However, little is known about the 
benefits and health risks of e-cigarette use. Although e-cigarettes have been shown to have 
negligible effect on carbon monoxide exposure and heart rate, they contain a variety of glycerols 
mixed with variable concentrations of nicotine. In addition, other substances are present in the 
refill solutions and/or resulting vapor, such as tobacco specific nitrosoamines, cotinine, aldehydes, 
metals, volatile organic compounds, tobacco alkaloids, and other pharmacologically active 
ingredients (although in concentrations much lower than in combustible traditional cigarettes). In 
addition, studies have shown that during the atomization process, there is a large range in the size 
of the particulate matter formed that is dependent upon both the device and refill solution used. It 
is well know that inhaled particulate matter may induce inflammation and may eventually lead to 
an increase in a variety of health risks including cardiovascular disease and emphysema. 
Although e-cigarettes are not currently regulated, studies have indicated that the e-liquid products 
should be regulated to ensure consistent nicotine delivery and to prohibit the use of ethylene glycol 
and other excipients that currently may be present at potentially harmful amounts (high risk 
category). Additionally, only minimal valid data are available related to the biodistribution 
(deposition of nicotine and/or aerosol excipients) following inhalation. The evaluation of nicotine 
and aerosol deposition in the body will help to determine if the particulates formed during the 
atomization process may induce any serious health risks. Additionally, these data may be 
compared to traditional cigarette smoking to determine if e-cigarettes are truly a safer alternative 
to conventional cigarettes. In order to provide these data, quantitative methods need to be 
developed that allow for accurate in vivo biodistribution determination following inhalation. 
Radioactive carbon (11C) biodistribution studies have been reported in the literature for traditional 
cigarettes. Here, cigarettes are laced with 11C-nicotine, and the biodistribution following inhalation 

THE OHIO STATE UNIVERSITY 
 
Institutional Review Board 
Version: December 20, 2017 
Page 3 of 16 
is evaluated using positron emission tomography (PET). The aim of the current study is to establish 
the methodology required to evaluate the biodistribution of 11C-nicotine labeled refill solution 
following e-cigarette inhalation using digital PET/CT and/or conventional PET/CT. Once 
established, these methods will be applied to determine the biodistribution of e-cigarette aerosol. 
RESEARCH DESIGN AND METHODS 
Methods Overview 
Potential participants will be identified using advertisements including brochures and online 
postings. After participants are identified, their eligibility will be determined using survey tools.  
All eligible participants will first have a screening visit at the WCIBMI for study participation. 
During this initial visit, subjects will be informed about the study in detail, and the relevant consent 
form will be reviewed and signed. If they agree to participate, they will go through a full dress 
rehearsal. Up to 10 volunteers will only participate in the dress rehearsal. All other volunteers will 
have a dress rehearsal without radiation exposure on day 1, and then on a second day, they will 
participate in the full imaging study using 11C-nicotine.   
During the imaging study, S-nicotine will be labeled with 11C and placed in the cartridge of an e-
cigarette. At the time of initial inhalation, the S-nicotine will be formulated using of 11C purified 
by HPLC. 
There will be two different dosage groups: 
A, 3mCi dosage of 11C-nicotine placed into the e-cigarette 
or 
B, 9 mCi dosage of 11C-nicotine placed into the e-cigarette 
The target dose will be the 3mCi dosage. Current investigational research by other groups uses 
dose levels of 10-20mCi. Based on our simulations, we predict that the 3mCi dose level will be 
sufficient but we will not know. Therefore we are including a second dose level group as an 
alternate which will still be below dose levels reported by other groups. 
Subjects will take a maximum of 10 puffs (1 puff per 30 seconds) from the e-cigarette while 
positioned in the PET/CT system.  
Dynamic PET/CT imaging will be performed for a maximum of 60 minutes following inhalation.  
The subject will be placed in the PET camera in order to generate axial images of the following 
regions: head/neck (e.g., brain, oral cavity, and throat) and thorax (e.g., trachea, lungs). 
From the PET/CT images, quantitative radioactivity deposition will be determined, and the 
biodistribution and uptake/clearance will be evaluated.  
PET data will be acquired in listmode and subsequently used for simulation to determine the 
potentially lowest dose feasible using the next generation digital PET/CT technology.  
Recruitment  
Potential participants will be identified through brochures, contact with vape shops, and social 
media postings. Brochures will be distributed at vape shops, and social media postings will be 
made in interest groups. A link to an informational video will also be provided in the brochure. To 
determine eligibility, participants will sequentially complete two eligibility surveys. 

THE OHIO STATE UNIVERSITY 
 
Institutional Review Board 
Version: December 20, 2017 
Page 4 of 16 
Survey 1 
The brochures and social media postings will include a link to Eligibility Survey 1. Survey 1 will 
collect sensitive, medical information, but will be completely anonymous. Medical information 
will be collected solely for the purposes of determining participant eligibility and will be unlinked 
from any identifying participant information as well as future collected study data.  
Survey 2 
Once participants are determined eligible by Survey 1, they will be directed to complete Survey 2 
to confirm their eligibility. Survey 2 will ask participants questions about their vaping habits. If 
they are confirmed eligible from the survey, they will also be asked to provide their name and 
contact information (e-mail). Study personnel will then contact eligible participants to schedule a 
time for them to come to the WCIBMI for their initial visit. Responses from Survey 1 and Survey 
2 will be completely unlinked to maintain anonymity about participants’ medical information. 
Selection Criteria 
Inclusion Criteria 
• 
Males and females of 18 years of age or older 
• 
Current regular user of e-cigarettes (use at least once daily for the past 30 days) with 
nicotine strength > 6 mg/ml. 
• 
Healthy medical history  
• 
Abstinent from any tobacco/nicotine use for 4 hours prior to imaging 
Exclusion Criteria 
• 
Not a regular user of e-cigarettes 
• 
Pregnant or lactating (only excluded from imaging study) 
• 
Prisoner 
• 
Incapable of giving informed consent 
• 
Being claustrophobic  
• 
Unable to lie flat on the scanner for extended periods of time 
• 
Unstable medical condition such as heart disease, uncontrolled hypertension, thyroid 
disease, diabetes, renal or liver impairment, or glaucoma 
• 
Prostatic hypertrophy, stroke, ulcer in the past year 
• 
Psychiatric conditions such as schizophrenia, adult ADHD, or bipolar disorder 
• 
Current or regular use of psychiatric medications such as tranquilizers, antipsychotics and 
anti-depressants 
• 
Use of medications that are inducers of CYP2A6 (a nicotine metabolizing enzyme) such 
as rifampicin, dexamethasone, phenobarbital, and other anti-convulsion drugs 
• 
Unable to communicate in English 
• 
Current use of smokeless tobacco, tobacco cigarettes (5 or more per day). Occasional use 
of pipes or cigars is permitted if subject abstains for the week prior to the study  
• 
Older than 80 years 

THE OHIO STATE UNIVERSITY 
 
Institutional Review Board 
Version: December 20, 2017 
Page 5 of 16 
Participant Procedures 
Cold – Volunteers – No imaging - full dress rehearsal without radiation exposure (Single day 
participation) 
In order to optimize the procedural setup of our imaging methodologies, we will recruit up to 10 
cold volunteers to only complete a dry run / dress rehearsal of the study. These volunteers will be 
taken through the study process without the use of the 11C–nicotine e-cigarette and without 
performing any imaging. The volunteers will eligible to join the full imaging study. 
Imaging Volunteers – full study with imaging session (Two-day participation) 
A maximum of 30 subjects will be included in the imaging portion of this study. Similar to the 
cold / dress rehearsal volunteers, these participants will complete an initial dress rehearsal visit at 
the WCIBMI to walk through the study procedures. However, the full study participants will also 
return to the WCIBMI on a second date to complete the imaging study with the 11C-nicotine e-
cigarette. Bergstrom et al. (Clinical Pharmacology and Therapeutics, 1995; 57(3):309-17) has 
reported a relative percent deviation of 34% in the total dose released following 5 minutes of 
aerosol inhalation (15.4 +/- 5.3%). Assuming an alpha value of 0.05 and a power of 0.8, a sample 
size of at least 8 subjects is required to observe significant differences in the dose released. One of 
the aims of this study is to evaluate the next generation PET/CT technology that may exhibit 
different variance. As a result, larger populations are likely required in order to evaluate a 
significant difference between the groups. If the power is set to 0.95 to account for this, then the 
number of subjects required per group is 14. In order to ensure significance and to account for any 
subjects that do not comply, a total of 30 subjects is requested.  Subjects may enroll up to two 
times (i.e., repeat the imaging study with 11C-nicotine one additional time), but the second 
enrollment must be at least one week after the first visit. 
 
Figure: Schematic of participant procedures. After determined eligible via eligibility surveys, 
participants will be invited to the WCIBMI to complete the relevant consent forms. If they are 
participating in the full study, they will first participate in the dress rehearsal, and then study 
personnel will schedule a time for the participant to return to the WCIBMI and complete the full, 
imaging portion of the study. If they are participating in only the dress rehearsal, they will not 
receive any radiation or imaging, and they will receive compensation at the end of the dress 
rehearsal. 
Measurement / Instrumentation  
PET/CT imaging will be predominately performed on the next generation digital photon counting 
PET/CT (Vereos); however, the mobile conventional PET/CT (Gemini TF 64) that is parked on 
the Martha Morehouse facility will serve as a backup PET/CT imaging system in case of any 
technical reasons. Our main focus is to utilize the digital PET system, but we need and want the 
Eligibility 
Survey 1
Eligibility 
Survey 2 
WCIBMI 
Visit
Consent
Dress 
Rehearsal 
(n = 10 
volunteers)
Dress 
Rehearsal 
(n = 30 
volunteers)
WCIBMI 
Visit
Imaging 
Study
$100 
compensation
$250 
compensation

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THE OHIO STATE UNIVERSITY 
 
Institutional Review Board 
Version: December 20, 2017 
Page 7 of 16 
 
Figure: Subject positioned head-first on PET/CT system. A test subject will be positioned on 
the system with the fan for directional air flow on one side (center). The image on the far right 
depicts the plastic enclosure open to show the rear view of the subject position. 
11C-nicotine Dosage 
As has been reviewed in a broad collaboration with Medical Physics and Radiation Safety and 
agreed in consensus with the RSO, the maximum dose that we may mix into the vape fluid is 9 
mCi of 11C-nicotine. Initially, we will use a dosage of 3 mCi (Dose level A); however, if this 
dosage does not yield adequate image quality, the dosage will be raised to 9 mCi (Dose level B) 
for subsequent participants. Due to this low dose approach and the short half-life of 11C (i.e., 20.3 
min), the directional airflow with a HEPA filter is sufficient for removing and absorbing the 
residual vape/aerosol. After a subject completes an 11C-nicotine vaping session, the PET/CT 
imaging area will be considered radioactive until 20 half-lives (i.e., 406 min) have passed. The 
imaging area will be marked as “Do not access” until the next morning. 
Schematic of an e-cigarette  
The following figure details the components of the e-cigarette. During the dress rehearsal, a user 
manual will be provided to the subject and will be reviewed for the subjects participating in 
imaging. 
           
 
Figure: E-cigarette schematic. The e-cigarette system that will be used is Itazte VV (left). The 
e-cigarette components are detailed in the schematic of a generic e-cigarette (right; source: 
Wikimedia.org). 

THE OHIO STATE UNIVERSITY 
 
Institutional Review Board 
Version: December 20, 2017 
Page 8 of 16 
DETAILED STUDY PROCEDURES 
Screening Visit – Dress Rehearsal  
Once the participant has been identified and indicated interest in participation, they will be invited 
to the WCIBMI to see the facilities, experience being in the PET/CT device (i.e., to determine if 
the subject is claustrophobic), and sign the informed consent and HIPAA if they remain interested 
in participating.  
For those subjects that have indicated their interest to participate in the imaging study, the 
following additional steps will occur during the dress rehearsal visit: 
• Participants will be informed about the further study details, the consent form will be 
reviewed and signed, and an imaging date will be scheduled.  
• Participants will be given the e-cigarette that will be used in the study so that they can get 
accommodated to the device and practice vaping in the supine position. 
• For female subjects participating in the imaging procedure, urine will collected during the 
screening visit to confirm that they are not pregnant.  
All subjects participating in the imaging study will be required to have a full dress rehearsal at the 
WCIBMI prior to their imaging procedures in order to practice and be familiar with the study 
facilities/procedure: the gowning into hospital scrubs and protective gear, the proper posture for 
PET scanning, and the e- cigarette vaping and exhaling procedure. There will be no PET/CT 
imaging or 11C-nicotine radiation exposure during the dress rehearsal. 
Subjects who initially agree only to the dress rehearsal are eligible to add the subsequent imaging 
study without an additional dress rehearsal unless requested by the PI. The subject will complete 
appropriate consent documentation of their expanded participation. The dress rehearsal and 
subsequent 11C-nicotine PET/CT imaging examination will follow the same steps. 
Subject Gowning 
The subject will wear hospital scrubs and personal protective gear in order to minimize any 11C 
radioactive deposits from the exhaled vape. The subject will also wear two sets of gloves. The 
gowning will be guided and monitored by research project personnel. 
 
Figure: Subject gowning procedure. Still pictures from a training video demonstrate the subject 
gowning procedure with personal protective gear.  

THE OHIO STATE UNIVERSITY 
 
Institutional Review Board 
Version: December 20, 2017 
Page 9 of 16 
Subject Positioning on the PET/CT System 
After gowning, the subject will be placed on the PET/CT system. A knee support pad and a head-
holder will be available and used to improve subject comfort and minimize subject motion.  
Once the subject is comfortably positioned, the surview scan will be performed using CT only, 
and the PET/CT imaging field will be planned. Once the imaging field is determined, an 
attenuation CT scan of the imaging field will be acquired. 
The e-cigarette will be brought to the PET/CT suite in a transport box. Once all preparations are 
completed for the PET image acquisition, the subject will be given the e-cigarette.  
 
Figure: Subject positioning procedure. These still pictures from a training video demonstrate 
the subject positioning procedure on the PET/CT system, including the process of handing over 
the e-cigarette (lower center), and the process for the subject to hold the e-cig during vaping (lower 
right). 
E-cigarette Vaping  
The following figure presents still pictures from the training video to demonstrate the handover of 
the e-cig to the subject, how the subject should handle the e-cig, and the process of vaping as 
instructed with up to 10 puffs. 

THE OHIO STATE UNIVERSITY 
 
Institutional Review Board 
Version: December 20, 2017 
Page 10 of 16 
 
Figure: 11C-nicotine e-cigarette puffing procedure. Still pictures from a training video 
demonstrate the handling of the c-cig in the PET/CT system, the handover to the subject, handling 
of the e-cigarette during vaping, and return of the device to staff.  
Subject De-gowning 
The following figure presents still pictures from the training video to demonstrate the de-gowning 
procedure of the participant.  
 
Figure: Subject de-gowning procedure. Still pictures from a training video demonstrate the 
participant de-gowning procedure. The participant will remove and dispose of all personal 
protective gear, and study personnel will subsequently evaluate the radiation levels of the 
participant.  
Imaging Visit 
All subjects will be contacted 24-48 hours prior to the imaging study to confirm their availability 
and continued participation. The procedures detailed for the dress rehearsal will also be followed 
for the imaging session. The subject will again disrobe and change into hospital scrubs. The subject 

THE OHIO STATE UNIVERSITY 
 
Institutional Review Board 
Version: December 20, 2017 
Page 11 of 16 
will wear full-body disposable personal protective equipment (PPE) including a gown, hairnet, 
double latex gloves, and foot coverings.  
The subject will be positioned on the PET/CT during the transport of the 11C- e-cig material from 
Kinnear to the WCIBMI (15 minutes prior to study of vaping).  
Once the 11C-nicotine e-cigarette enters the PET/CT facility, it will be placed into the facility’s 
dose calibrator for a secondary dose confirmation and then transported directly to the PET/CT 
imaging room. The subject will then be instructed to start inhalation (maximum 10 puffs at 30 
second intervals) while positioned in the PET/CT system. Afterwards, the used e-cigarette will be 
removed from the imaging system by a staff member, and its remaining residual 11C-nicotine 
activity determined using a dose calibrator.  
PET imaging will be performed for a maximum of 60 minutes following onset of 11C-nicotine 
inhalation/vaping. After PET imaging is completed, the subject will be de-gowned, and the 
radiation levels will be determined. The subject will be asked to stay in the patient waiting/recovery 
area for up to 120 minutes (2 hours). Prior to release, the subject will be surveyed again to ensure 
that any exhaled breath/air is at background radioactivity levels. Additionally, all subjects will be 
contacted within 24 – 48 hours after release from the study to ensure that they are feeling well and 
have not experienced any adverse reaction to the study. Any adverse reactions will be recorded 
and reported immediately to the PI.  
The medical records for the subjects will not be obtained for this study. Participants will be asked 
to provide medical information in an eligibility survey only to confirm their eligibility. Responses 
to this survey will be entirely anonymous and confidential. In addition, there will be no personal 
data recorded other than the subject’s gender, age, ethnicity, weight, height, and length of time that 
they have been smoking and/or using e-cigarettes. All subject data will use coded identifiers in all 
imaging files with subject numbers replacing the typically patient name fields.  
Imaging 
All PET/CT imaging will be performed using the Vereos digital PET/CT and/or the mobile 
conventional Gemini PET/CT systems located at the WCIBMI. The subject will lay supine and 
therefore must be able to inhale/vape in this position. The subject will be placed in the PET camera 
as to generate axial slices in the following regions: head/neck (e.g., brain, oral cavity, and throat) 
and thorax (e.g., trachea, lungs). CT image acquisition will be at the lowest dosages possible for 
accurate anatomic localization of 11C radioactivity on the PET images (80KV, 30mAs, 3D dose 
modulated). Dynamic PET images will be acquired over a time period of up to 60 minutes 
following the start of 11C-nicotine inhalation/vaping. The total PET imaging scan time will not 
exceed 60 minutes per subject. The total time in the imaging suite will be a maximum of 85 minutes 
for each subject (15 minutes prior to scanning, <5 minutes for inhalation, <2 minutes to remove e-
cigarette, and up to 60 minutes scanning). Once the subject leaves the imaging suite, the imaging 
suite will be surveyed. If the radioactivity is above background levels, the suite will be locked and 
the PET/CT imaging area will be considered radioactive until 20 half-lives (i.e., 406 min) have 
passed. The imaging area will be marked as “Do not access” until the next morning and 
subsequently surveyed no sooner than every 30 minutes until background levels of radioactivity 
are achieved.  
Optimal PET imaging parameters will be utilized for each PET/CT system and, as a result, may 
differ between the conventional Gemini and next generation digital Vereos systems. However, 

THE OHIO STATE UNIVERSITY 
 
Institutional Review Board 
Version: December 20, 2017 
Page 12 of 16 
time of flight acquisition with lost mode recording will be used on both systems. For example, the 
digital Vereos system is able to acquire PET images with faster timing resolution and with lower 
voxel sizes compared to the conventional Gemini system. The PET image acquisition parameters, 
however, will be held constant on each individual system.  
11C Labeling 
11C-labeled S-nicotine will be produced at the Kinnear Road facility following a gas-phase method 
developed by the WCIBMI team (Gosh A. et al, Applied Radiation & Isotopes, 2017, submitted) 
according to applicable production guidelines for inhalants. In short, purified 11C-labeled S-
nicotine will be diluted with the e liquid. The 11C-labeled S-nicotine concentration, radiochemical 
purity, and specific activity will be determined. Appropriate amount of the e liquid containing 11C-
labeled nicotine will be loaded in the e-cigarette cartridge. The radioactivity in the cartridge will 
be determined, and the e-cigarette will be placed in a lead syringe holder, which will be delivered 
to the WCIBMI imaging facility at Kenny Road. 
11C Dose  
The total radioactivity in the cartridge of the e-cigarette will not exceed 9 mCi delivered to the 
patient. Initially, we will use a dosage of 3 mCi (Dose level A); however, if this dosage does not 
produce adequate image quality, the dosage will be raised to 9 mCi (Dose level B) for subsequent 
participants. The release of radioactivity is expected to be 15 +/- 5% during the inhalation phase 
(Bergstrom et al, Clinical Pharmacology and Therapeutics, 1995; 57(3):309-17). The total 
delivered dose to the subject will be determined and recorded. 
Data Analysis 
All PET images will be reconstructed to generate quantitative images for absolute determination 
of radioactivity distribution. Corrections for the decay of 11C will be applied. The deposition will 
be shown in 3D and co-localized relative to the anatomy (as provided by the CT images). The total 
radioactivity will be determined in the head/neck and thorax (e.g., brain, oral cavity, trachea, 
esophagus, bronchi, lungs, and other relevant soft tissues like muscle). Analysis of other tissues 
within the imaging field of view may be performed if 11C activity is observed.  
The biodistribution, uptake, and clearance will be evaluated in the specified tissues. The results 
obtained using conventional PET/CT will be compared to the results obtained using the new digital 
technology. The percent variance in the total radioactivity will be determined at each time point 
for each tissue. 
We are not performing intra-individual comparator examinations. We are focusing on assessing 
the new generation digital technology and have comparable historical benchmark data available 
for comparison.  
Compensation  
Each subject who participates will be eligible for compensation. 
The volunteers who participate in the dress rehearsal only (i.e., no 11C-nicotine exposure and no 
PET/CT imaging) will receive a $100 Visa gift card.   
Subjects who participate in the complete study (i.e., dress rehearsal and 11C-nicotine PET/CT 
imaging) will receive a $250 Visa gift card, which will be provided to them after completion of all 
study requirements. 

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By law, payments to subjects are considered taxable income.  
Incidental Findings 
Imaging incidental findings will not be observable in this study as the PET and CT imaging will 
not be of diagnostic quality.  
RISKS, BENEFITS, SAFETY, AND CONFIDENTIALITY 
Risks 
Overall, the risk/benefit ratio of this study is minimal since the probability and magnitude of harm 
or discomfort anticipated in the study are not greater than what is ordinarily encountered during 
the performance of a routine PET/CT.  
Minimal risk exists during any PET imaging. Risks are mainly due to potential impingement by 
the moving table and falling off the imaging table. 
Radiation Risk 
Dose Level A (3 mCi 11C-nicotine Dosage) 
Participants will receive a e-cigarette with an total dosage of 3 mCi from the 11C-nicotine, of which 
only a fraction will be inhaled by the participant. For the 3 mCi dosage, the PET radiotracer will 
yield minimal radiation exposure of 0.64 mSv.  
The attenuation CT will add 0.8 mSv EDE to the overall dose exposure. For the 3 mCi 11C-nicotine 
dosage, the combined and total EDE is 1.44 mSv. On average, a U.S. resident receives an annual 
radiation exposure from natural sources of about 3.6 mSv. The 1.44 mSv EDE is equivalent to 4.8 
months or 146 days of natural radiation exposure. The calculated corresponding BEIR VII risk 
estimate may range from about one in 48,906 (0.002%) to about one in 20,469 (0.005%).This is 
considered minimal risk. 
9 mCi 11C-nicotine Dosage 
If necessary, the 11C-nicotine dosage may be raised to 9 mCi. Only a fraction of this dosage will 
be inhaled by the participant. From this dosage, participants will receive a minimal radiation 
exposure of 1.90 mSv.  
The attenuation CT will add 0.8 mSv EDE to the overall dose exposure, so the combined and total 
EDE is 2.70 mSv for the 9 mCi 11C-nicotine dosage. The 2.70 mSv EDE is equivalent to 9 months 
or 274 days of natural radiation exposure. The calculated corresponding BEIR VII risk estimate 
may range from about one in 11,575 (0.0086%) to about one in 4,845 (0.021%).  
For both 11C-nicotine dosage levels, we can compare this possible extra cancer risk to other risks 
(over a lifetime) that everyone is subject to in everyday life. For example, the chances of a person 
dying of cancer with no extra radiation exposure are about one in 4. The chances of dying in a car 
crash are about one in 82, and the chances of being killed by a car while crossing the street are 
about one in 730. 
Participants who only complete the dry run portion of the study will have no radiation exposure or 
risk. 
Adverse Reactions 

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Overall, there is minimal risk for serious adverse reactions as a consequence of enrolling in this 
study. There will be no IV injections. The 11C-nicotine will be inhaled as part of the e-cig vaping 
process. Adverse reactions will be assessed and reported as required.  
Inconvenience 
The subjects may experience inconvenience due to the study procedures. Inconvenience will be 
addressed through monetary compensation of participants.  
Benefits 
There will be no direct benefits to the subjects for participating in the study; however, this study 
will further scientific knowledge about the health risks of e-cigarettes and the sites of nicotine 
deposition following e-cigarette use.  
INTERNAL VALIDITY 
Image data will be evaluated at a minimum following standard published procedures. This includes 
but is not limited to visual evaluation of uptake, normal tissue, and imaging artifacts, semi-
quantitative analysis, blinded reader analysis, and using various methods for image post-
processing. This should ensure internal and external validity of the data and avoid study bias. 
Functional and molecular imaging read outs will be developed according to established 
methodologies. 
Managing and verifying the internal validity is an important task in this exploratory research 
program in order to develop the appropriate methodology to be validated in prospective clinical 
trials.  
As there is an opportunity that the staff member administering the facility experience can 
potentially bias the subject, we will perform training sessions with the staff prior to them 
administering the facility experience. We will also perform from time to time an observational 
assessment by a study member participating in the subject facility experience with the task to 
observe the team member administering the facility experience in order to ensure that no bias or 
systematic errors occur.  
In this exploratory study, we will have to constantly assess the potential sources of systematic 
errors or bias in order to ensure that we may derive conclusions that warrant generalization to other 
contexts. 
We will assess the different factors impacting internal validity of the data sets we generate. For 
the specific factors we will address the following considerations. The following text uses material 
presented 
at 
https://en.wikipedia.org/wiki/Internal_validity 
and 
is 
hereby 
specifically 
acknowledged. 
Temporal Precedence 
Potential lack of clarity how one experience may influence a subsequent experience as that might 
be a cause and effect relationship. 
Confounding 
A major threat to the validity of causal inferences is confounding. Observations in one variable 
may relate to another manipulated variable. Where spurious relationships cannot be ruled out, 
hypothesis would have to be appropriately developed. 

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Selection Bias 
Selection bias refers to the problem that, at pre-test, differences between groups exist that may 
interact with the independent variable and thus be 'responsible' for the observed outcome. 
Researchers and participants bring to the experiment a myriad of characteristics, some learned and 
others inherent. For example, sex, weight, hair, eye, and skin color, personality, mental 
capabilities, and physical abilities, but also attitudes like motivation or willingness to participate. 
During the selection step of the research study, if an unequal number of test subjects have similar 
subject-related variables there is a threat to the internal validity. If subjects in two groups to be 
compared are not alike with regard to the independent variable, but similar in one or more of the 
subject-related variables, it may jeopardize the internal validity. 
Self-selection to participate in this research can have a negative effect on the interpretive power of 
the dependent variable, this is especially known for online surveys where individuals of specific 
demographics opt into the test at higher rates than other demographics. 
History 
Events outside of the study/experiment or between repeated measures of the dependent variable 
may affect participants' responses to experimental experiences. Often, these are large scale events 
(natural disaster, political change, etc.) that affect participants' attitudes and behaviors such that it 
becomes impossible to determine whether any change on the dependent measures is due to the 
independent variable, or the historical event. 
Maturation 
Subjects may change during the course of the experiment or even between measurements. Both 
permanent changes, such as physical growth and temporary ones like fatigue, provide "natural" 
alternative explanations; thus, they may change the way a subject would react to the independent 
variable. So upon completion of the study, the researcher may not be able to determine if the cause 
of the discrepancy is due to time or the independent variable. 
Repeated Testing 
Repeatedly measuring the participants may lead to bias. Participants may remember the answers 
or may be conditioned to know that they are being tested. Repeatedly taking (the same or similar) 
tests usually leads to score gains. 
Instrument Change 
The instrument used during the testing process can change the experiment, an aspect that we will 
managed via device quality control to the largest extent possible. This also refers to observers 
being more concentrated or primed, or having unconsciously changed the criteria they use to make 
judgments. This can also be an issue with self-report measures such as facility perceptions given 
at different times. In this case the impact may be mitigated through the use of retrospective 
pretesting. If any instrumentation changes occur, the internal validity of the main conclusion is 
affected. 
Differential Attrition 
This error occurs if inferences are made on the basis of only those participants that have 
participated from the start to the end. However, participants may have dropped out of the study 
before completion, and maybe even due to the study or experiment itself. If this attrition is 

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systematically related to any feature of the study, the administration of the independent variable, 
the instrumentation, or if dropping out leads to relevant bias between groups, a whole class of 
alternative explanations may be possible that account for the observed differences. 
Selection-maturation Interaction 
This occurs when the subject-related variables, color of hair, skin color, etc., and the time-related 
variables, age, physical size, etc., interact. If a discrepancy between the two groups occurs between 
the testing, the discrepancy may be due to the age differences in the age categories. 
Experimenter Bias 
Experimenter bias occurs when the individuals who are conducting an experiment inadvertently 
affect the outcome by non-consciously behaving in different ways to members of control and 
experimental groups. It is possible to eliminate the possibility of experimenter bias through the use 
of double blind study designs, in which the experimenter is not aware of the condition to which a 
participant belongs.