Biological Pathways in Stress Reactivity and Nicotine Addiction Among African American and White Smokers
Conditions: Smoking, Smoking Behaviors, Smoking Cessation, Stress Reaction
Sponsor: Virginia Commonwealth University

Version 1; Version Date: 11/9/2021 
 
Page 1 of 14 
 
 
PROTOCOL TITLE: 
Biological Pathways in Stress Reactivity and Nicotine Addiction among African American and White 
Smokers 
 
PRINCIPAL INVESTIGATORS: 
Chanita Hughes-Halbert, PhD, Principal Investigator 
 
Gayenell Magwood, PhD, RN, FAHA, FAAN, Site Investigator 
 
 
 

Version 1; Version Date: 11/9/2021 
 
Page 2 of 14 
 
  
1.0 
Objectives / Specific Aims 
This study will examine racial differences in stress responses between African American and white male 
smokers as part of the Translational Research Center in Lung Cancer Disparities (TRACER).   
 
• 
Aim 1: Examine racial differences in acute physiological stress responses between African 
American and white male smokers using a laboratory model. The association between 
acute physiological stress response and tobacco-related behaviors will also be evaluated.  
Hypotheses: African American smokers will be more likely than white smokers to have a 
blunted cortisol response to an acute laboratory stressor. African American smokers will 
also have significantly greater cigarette craving and be more likely to smoke following 
exposure to an acute physiological stressor compared to white smokers following an acute 
laboratory stressor.  
• 
Aim 2: Evaluate racial differences in daily cortisol patterns between African American and 
white male smokers.  
Hypotheses: African American smokers will be more likely than white smokers to have 
blunted daily diurnal cortisol slopes. Compared to white smokers, African American 
smokers will have lower absolute cortisol values during the waking day.  
• 
Aim 3: Identify factors that are important to acute and daily stress responses among African 
American and white male smokers by examining acute and daily cortisol patterns based on 
exposure to chronic stressors.  
Hypotheses: Acute and daily cortisol responses will be associated with chronic stressors 
such that men who have greater exposure to SES, structural, and psychosocial stressors 
will have blunted acute and daily cortisol patterns. The relationship between acute and daily 
cortisol patterns, nicotine metabolism, and nicotine dependence will also be explored 
among African American and white male smokers as part of this aim. 
• 
Aim 4: Examine social and clinical factors associated with study enrollment and retention. 
Hypotheses: Those with greater comorbidities and social issues (i.e. lower SES,  
education, social support) will have lower rates of study enrollment and retention 
compared to those with fewer comorbidities and social issues. 
 
2.0 
Background 
Cigarette smoking is a leading cause of morbidity and mortality from lung cancer among adults in the US; 
smoking cessation is the best preventive strategy for reducing lung cancer risk and addressing racial 
disparities in outcomes. Despite this, many smokers are unwilling or unable to make a quit attempt, and 
among those who try to quit smoking, utilization of evidence-based treatment is poor, especially in racial 
minorities. Stress relief, and the avoidance of adverse psychological and physiological reactions, are 
among the primary reasons for smoking initiation, maintenance, and relapse in all populations. Stress 
responses have both psychological and physiological consequences that are important to smoking 
behaviors and cessation outcomes, and racial differences in physiological stress responses have not been 
examined between African American and white smokers. 
 
Physiological stress responses are among the multilevel determinants of cancer health disparities that 
need to be examined within the context of other SES, psychosocial, and structural factors. This study will 
be the first to examine racial differences in stress responses between African American and white male 
smokers at increased risk for lung cancer morbidity and mortality by measuring acute cortisol responses 
to a laboratory stressor and evaluating racial disparities in daily cortisol patterns among these men in their 

Version 1; Version Date: 11/9/2021 
 
Page 3 of 14 
 
neighborhoods and communities. Together with contextualized data on acute and chronic stress 
responses based on SES, psychosocial, and structural factors, this study will generate novel empirical 
data that can be leveraged into precision strategies for lung cancer prevention through smoking cessation 
and other intervention approaches.   
 
3.0 
Study Setting 
This study will be conducted at MUSC Health.  Participants will be identified using electronic health records 
(EHR) and will participate in laboratory visits at the Research Nexus Laboratory in the Clinical Sciences 
Building at MUSC to measure acute stress responses.  All baseline and follow-up assessments will be 
conducted by telephone or online using a redcap weblink.  This study is being conducted as part of the 
Translational Research Center in Lung Cancer Disparities (TRACER) that includes: MUSC, the Massey 
Cancer Center at the Virginia Commonwealth University (VCU), and the City of Hope Comprehensive 
Cancer Center (COH). 
 
4.0 
Inclusion and Exclusion Criteria/ Study Population 
 
Primary care patients at MUSC Health will be identified using EHR and those who meet inclusion criteria 
will be contacted by telephone to complete a screening interview and baseline assessment that measures 
socioeconomic stressors and other variables.  To be eligible to participate in the study, the following criteria 
will be applied.  
 
Inclusion Criteria  
• African American and white males 
• Between the ages of 18-75 years old  
• Smoke at least 5 to 10 cigarettes per day 
Exclusion Criteria 
• Smokers who have a serious cognitive disorder or psychiatric illness  
• Have a personal history of lung cancer 
• Personal history of usage of illicit drug and alcohol abuse  
• Enrollment in a smoking cessation treatment program during the past 6-months 
• Current use of a nicotine replacement therapy 
• Have any positive response on the Mini International Neuropsychiatric Interview (MINI) 
screener 
 
5.0 
Number of Subjects 
The study will enroll 100 African American (n=50) and white (n=50) male smokers.  
 
6.0 
Recruitment Methods 
 
Two recruitment strategies will be used to identify smokers to participate in the study. First, the initial 
recruitment strategy will be identifying patients by searching EHRs using smoking status and ICD-10 
diagnosis codes (e.g., smoking status, psychiatric illness, cognitive disorders) to identify smokers who are 
potentially eligible to participate in the study.  Additionally, text algorithms will be applied to chart notes to 
help supplement the EHR search because smoking behaviors may be under-reported. Following 
identification and application of exclusion criteria to the EHR, a patient list of individuals who are identified 
as current smokers and meeting other eligibility criteria will be created and provided to the investigative 
team.  These patients will be mailed an invitation letter that describes the purpose of the study and the 
procedures involved in participation. The letter will also include a local number and email address to 
respond if they are not interested in being contacted for study participation. Those who do not opt out of 

Version 1; Version Date: 11/9/2021 
 
Page 4 of 14 
 
participation will be contacted for the baseline and screening telephone interview. The South Carolina 
Translational Research Center (SCTR) will conduct the EHR search and generate patient lists. Second, a 
community-based approach in which smokers self-refer for participation from newspaper, radio 
advertisements, and social media will be used to recruit study participants. For individuals who self-refer 
for study participation, the screening interview and baseline survey will be completed to determine eligibility 
and complete enrollment procedures. Marketing materials will be developed using a evidence-based 
community engagement strategies. Project investigators will consult with members of the community 
engagement core to develop materials that are tailored and appropriate. Once these materials are 
developed they will be submitted to the IRB for review and approval.  
 
 
7.0 
Consent Process 
 
This study will use the procedures described below to obtain informed consent for study 
participation.  
 
Electronic Health Record Data Abstraction. A full waiver of HIPAA Authorization is requested to 
generate the EHR query that will be used to establish the list of patients who are potentially eligible to 
participate in the study and to obtain other personal health identifiers (e.g., MRN, names, address, 
telephone numbers) for sending invitation letters and conducting recruitment calls. The waiver of HIPAA 
Authorization will also include permission to abstract clinical (e.g., co-morbidities, medications, vital signs) 
and socioeconomic data (e.g. insurance type, race/ethnicity), and to utilize text algorithms developed by 
BMIC to abstract information from clinical notes relating to smoking status.  Clinical and sociodemographic 
data abstracted from the EHR will be included in de-identified datasets for analysis of study outcomes 
relating to factors (i.e. zipcode, co-morbidities) associated with smoking behaviors, stress responses, and 
enrollment and retention . The outcomes rendered from the EHR data that is obtained will help to inform 
future studies that further address disparities relating to lung cancer risk. 
 
All PHI data will be collected at the time of screening. No further data collection occurs on these 
participants following screening and EHR abstraction under the full waiver. Further data collection for 
participants who choose to enroll will be covered under the partial waiver for the baseline interview, and 
the signed informed consent form and HIPAA if they choose to participate further in the study.  
 
Screening Interview and Baseline Survey. A waiver of written informed consent/partial waiver of 
signature element is requested to complete the screening interview and baseline survey. Patients will be 
read a statement of study information before obtaining verbal consent. Once verbal consent is achieved, 
the screening interview will be completed by telephone. Baseline surveys will be completed according to 
the participant’s preference either by telephone or through self-administration via a redcap survey weblink. 
 
Laboratory Visits and Biorepository Biospecimen Donation. This study will involve laboratory visits 
for biospecimen collection and stress assessments, followed by at-home saliva collections at two follow-
up timepoints (see section 8.0 for detailed methods). Written informed consent will be obtained at the Pre-
Challenge laboratory visit (1st laboratory visit) prior to the initiation of any study activities. The written 
informed consent will include permission to collect biospecimens (e.g. urine, saliva), completion of a social 
stress test, perform at-home saliva collection and smoking assessment following the laboratory visits, and 
to use data on exposure to chronic, psychosocial, and structural stressors obtained during the study. The 
informed consent will also include an option for participants to donate biospecimens to the TRACER 
Biorepository located at VCU. If consent for biospecimens and data is provided, this information will be 
processed and stored using the procedures described in study design and methods. Provision of consent 
for biospecimens and data among individuals who do not meet final eligibility determination will be 
recorded in the data management system. 
 

Version 1; Version Date: 11/9/2021 
 
Page 5 of 14 
 
To obtain written informed consent, the research assistant (RA) will meet participants in a private room to 
review the informed consent form (ICF) and answer questions about the procedures involved in 
participating in the study, describe the voluntary nature of study participation, and discuss procedures for 
withdrawing. Following the informed consent discussion, participants will immediately be asked to sign the 
ICF, the RA will also sign and date the ICF, and a copy of the signed ICF will be provided to participants. 
The original ICF will be filed in the participants study chart and stored in a locked file cabinet. The RA will 
also complete an informed consenting process documentation form that contains a checklist for the RA to 
adhere to while conducting the informed consenting process. This form will also be filed in the participant’s 
chart. 
 
 
 

Version 1; Version Date: 11/9/2021 
 
Page 6 of 14 
 
8.0 
Study Design / Methods 
 
This research is a prospective observational study that will measure acute and chronic stress responses 
among African American and white smokers.  Acute stress responses will be measured following exposure 
to a validated laboratory social stress test and chronic stress responses will be measured at 4- and 8-
weeks following the laboratory stress test using at home collection.  The procedures described below will 
be completed. 
 
Screening Interview and Baseline Assessment. A 30-minute telephone interview will be conducted by 
research assistants from MUSC to screen participants for initial eligibility and those who are eligible will be 
invited to enroll into the study and complete a baseline survey. Participants that agree to enroll into the 
study, will be given the option to participate in the baseline survey over the telephone or through self-
administration via a redcap survey link. The baseline survey will obtain information relating to 
sociodemographic characteristics and measure exposure to chronic economic stressors (e.g., low income, 
financial strain), psychosocial stressors (e.g., perceived stress, social isolation), exposure to structural 
stressors (e.g., violence, crime), and community perceptions and resources (e.g., collective efficacy). 
Additionally, other factors relating to smoking history, nicotine dependence, and reasons for smoking will 
also be measured, along with perceived risk and control over developing lung cancer, utilization of lung 
cancer screening, and interest in quitting smoking will also be measured during the baseline assessment. 
Zip code and street address will be confirmed as part of the telephone interview to mail financial incentives 
and send study reminders. Once participants completed the baseline survey, they will be invited to 
participate in the laboratory assessments described below.  
 
Laboratory Visits. This study will involve four laboratory visits that will include a pre-challenge visit (lab 
visit 1) to collect biospecimens, a stress exposure visit (lab visit 2) that will involve conducting the Trier 
Social Stress Test (TSST), and two visits (lab visits 3 and 4) at 4- and 8-weeks after the TSST visit to 
collect final saliva samples. Each visit is explained in more detail below. 
 
Pre-Challenge Visit. Following completion of the screening interview and baseline survey, participants 
will complete a pre-challenge visit to obtain urine samples that will be used to determine final eligibility.  
The pre-challenge visit will be completed at the Research Nexus Lab at MUSC. Participants will be asked 
to smoke as usual prior to the pre-challenge visit but to not eat or drink one hour before the session. During 
the Pre-Challenge Visit, screening tests will determine final eligibility, these include urine toxicology; 
individuals whose results indicate current substance abuse (e.g., cocaine) will be excluded (not eligible for 
further participation). Saliva samples will also be obtained during the pre-challenge visit to determine 
cortisol and cotinine levels using established salivary swab collection methods and validated thresholds. 
To further evaluate and confirm active smoking behaviors, a breath monitor will be used to measure levels 
of carbon monoxide in the blood. The MINI International Neuropsychiatric Interview (MINI) will be 
administered by a trained research technician to evaluate mental status and psychiatry exclusion criteria. 
Participants will be excluded from participation in the laboratory stress visit if they meet the exclusion 
criteria (e.g., positive responses on the MINI, or positive toxicology result). Participants eligible following 
pre-challenge visit will be scheduled for the stress exposure visit described below.  
 
TSST Stress Exposure Visit. The stress exposure visit will be completed within 72-hours of completing 
the pre-challenge visit. As with the pre-challenge visit, participants will be instructed to smoke as usual, 
but not to eat or drink during 1-hour prior to stress exposure visit. The number and brand of cigarettes 
smoked prior to the TSST will be recorded. Participants will be asked to smoke a single cigarette of their 
usual brand prior to initiating the stress test to standardize the time since last smoking. Fifteen minutes 
later, baseline clinical and subjective measures will be obtained. Clinical measurements will include heart 
rate and blood pressure using a standardized monitor, and saliva collection using a Salivette. Following 
collection of these baseline measures, participants will be escorted back to their room to start the TSST. 
The TSST is a standardized psychological stress challenge that has been validated and used extensively 
in research studies; a meta-analysis supports that it is the gold standard for evoking an HPA-axis stress 
response in a laboratory setting. The TSST (see TSST Procedures and Timeline) will be administered in 

Version 1; Version Date: 11/9/2021 
 
Page 7 of 14 
 
the Research Nexus Lab. Outcome measures (e.g., cortisol responses) will be collected prospectively 
during the stress exposure 
visit. Heart rate variability 
(HRV) and blood pressure 
will also be measured using 
standard 
medical 
equipment and procedures 
during the TSST. Cigarette 
craving 
and 
smoking 
behavior will be measured 
after the TSST has been 
completed. 
Specifically, 
smokers will rate their urge 
to smoke immediately after 
the last saliva sample has 
been taken as part of the 
TSST. After completing this 
self-report measure, they 
will be given the opportunity 
to smoke a cigarette using a pocket CReSS system that measures and records smoking topography (Puff 
#, Volume, IPI). Smoking behavior (smoke versus not smoke) will be recorded in the participant’s study 
chart and stored in study’s data management Redcap system. 
 
Post-Stress Test Saliva Collection. At the end of the TSST, participants will be given saliva kits 
(Salimetrics oral swab) to collect samples at home 4- and 8-weeks after the stress exposure visit. Self-
reported data on perceived stress and life experiences during the past month will also be obtained using 
validated instruments.  Standard collection procedures (e.g., avoid eating/drinking/brushing teeth within 1-
hour of sample collection; do not engage in vigorous physical activity; no alcohol within 12-hours of sample 
collection) will be provided to participants as an instructional sheet. Saliva will be collected at fixed intervals 
(upon wakening, 30-minutes after wakening, 4:00 pm, and 6:30 pm). The final 6:30pm saliva collection will 
occur at the Nexus Laboratory and participants will be instructed to return their other collected samples 
from home at this time. Collection dates will be based on the date the stress exposure visit was completed 
and sample collection procedures will be explained verbally and in writing at the end of the stress exposure 
visit. Participants will be given an instructional sheet for how to perform the sample collections. Participants 
will also be given a collection log to record the date and time of each collection, the number and brand of 
cigarettes smoked on the collection day, quit attempts, the amount of stress experienced during the past 
month, and positive and negative life experiences during the past month. Participants will be contacted the 
night before the collection date by telephone, email, and text to remind them about the sample collection 
date, collection and storage procedures, and the information that should be recorded in the sample 
collection log. Saliva samples will be collected at 4- and 8-weeks after the TSST to be consistent with the 
collection timepoints used in previous research with African American and white treatment-seeking 
smokers.  
 
9.0 Data Collection and Storage.  
 
9.1 
Specimen Collection and Banking for Future Use 
As described previously, biospecimens (urine, saliva) will be collected after obtaining written informed 
consent at the Pre-Challenge Visit and Stress Exposure Visit and these biospecimens will be stored at the 
Research Nexus Laboratory at MUSC to complete procedures related to determining eligibility (Pre-
Challenge Visit) and evaluating stress responses (Stress Exposure Visit). Saliva samples will also be 
obtained at home following the Stress Exposure Visit; these biospecimens will be processed and stored at 
the Research Nexus Laboratory until statistical analyses have been completed.  Once statistical analyses 
have been completed, biospecimens will be stored in the Nexus Laboratory until the end of the project 
period.  All biospecimens will be stored in the Nexus Laboratory using a unique numeric identification 

Version 1; Version Date: 11/9/2021 
 
Page 8 of 14 
 
number to link samples with participants.  Further, all biospecimens will be coded with a numeric identifier 
to link test results with (e.g., changes in cortisol, cotinine levels) with subject data obtained during the 
screening and baseline telephone interview and clinical data (e.g., co-morbidities) abstracted from 
electronic health records.  All linked subject data will be de-identified and stored in a secured, password-
protected database at MUSC using their identification number.    
 
Participants also have the option to provide written informed consent for biospecimens to be included in 
the TRACER Biorepository. The TRACER biorepository is located at VCU; biospecimens from this study 
will be shipped to the TRACER biorepository using standard shipping procedures.  The Project Manager 
for this study will work with Nexus staff to ensure that samples are sent to the TRACER Biorepository and 
to document receipt of biospecimens.  Additionally, de-identified participant-level data will be uploaded into 
a centralized database at the TRACER Biorepository.  Access to biospecimens, test results, and linked 
data will be limited to study investigators, research staff within the scope of their roles (e.g., Project 
Manager), and investigators in the TRACER Biorepository.  
 
9.2 Specimen/Banking for Future Use 
The TRACER Biorepository will bank biospecimens in the facility located at VCU and de-identified 
participant data (e.g., race, age, zip code, self-reported data on income, education, etc., and census level 
information on social determinants of health) that are linked with these biospecimens will be stored on a 
centralized, secure database in the TRACER Biorepository. This information will be stored in the TRACER 
Biorepository until the end of the project period.  At the end of TRACER, samples and de-identified 
participant data will be destroyed. Participants can request that their biospecimen/data be withdrawn from 
the TRACER Biorepository by submitting a Withdrawal of Informed Consent for Use of Specimens to the 
study project manager.  Once this request is received, biospecimens and data will be destroyed or removed 
from the TRACER Biorepository.   
 
Biospecimens and participant data collected as part of this study will be used in future research that is 
conducted by TRACER investigators and may include genomic/genetic analyses.  A standard process will 
be used to release biospecimens and data to TRACER investigators.  Specifically, TRACER investigators 
will submit a written Request for Samples.  The Request for Samples will describe the type of samples 
needed, the purpose of the study, and documentation of IRB approval or exempt from human subjects 
designation.  The Request for Samples will be reviewed by investigators in the TRACER Biorepository with 
a recommendation to approve or deny the request for samples.  The TRACER Executive Council will make 
final decisions about approving or denying the request for samples.  Only de-identified biospecimens 
and/or data will be released to TRACER investigators.  A Material Transfer Agreement/Data Transfer 
Agreement (MTA/DAT) will be established by TRACER institutions prior to inter-institutional data sharing 
and transfer of biospecimens and data. 
 
10. Data Management  
 
10.1 Statistical Considerations and Sample Size Justification by Specific Aim. This section describes 
the sample size and power estimates for the study and also describes the statistical analyses that will be 
completed to address the specific aims for the study.  
 
Aim 1: Examine racial differences in acute physiological stress responses between AA/Black and 
white male smokers using a laboratory model. The association between acute physiological stress 
response and tobacco-related behaviors will also be evaluated. Hypotheses: AA/Black smokers will 
be more likely than white smokers to have a blunted cortisol response to an acute laboratory stressor. 
AA/Black smokers will have lower absolute cortisol values during the acute stressor compared to white 
smokers. AA/Black smokers will have significantly greater cigarette craving and be more likely to smoke 
following exposure to an acute physiological stressor compared to white smokers following an acute 
laboratory stressor.  
 

Version 1; Version Date: 11/9/2021 
 
Page 9 of 14 
 
Sample Size and Power Calculations: This aim will examine racial disparities in cortisol responses to an 
acute stressor among AA/Black and white male smokers in a laboratory setting. Changes in cortisol levels 
will be the primary outcome variable and will be measured multiple times during the course of the TSST. 
A sample size of 50 AA/Black (Mean DCS=0.20, SD=0.20) and 50 white (Mean DCS=0.35, SD=0.30) 
males achieves 84% power to detect a difference of 0.15μg/dL between the 2 groups with a significance 
level of 0.05 using a two-sided two-sample t-test. This sample size would also provide 80% power to detect 
a difference of 0.14μg/dL in absolute cortisol value between AA/Black (mean=0.17, SD=0.19) and white 
(mean=0.31, SD=0.30) males with a significance level of 0.05 using a two-sided two-sample t-test.  
 
Statistical Analysis: First, descriptive statistics will be generated to characterize enrollment outcomes using 
clinical data (e.g., co-morbidities, age, etc) obtained from the EHR during the recruitment process.  
Statistical analyses will compare enrollees vs. decliners in terms of race, clinical factors, and smoking 
history to identify variables that should be controlled for in the analysis of stress reactivity and smoking 
behaviors.  
 
To examine the effects of race on acute stress responses to the TSST laboratory stressor the response 
area under the curve (rAUC) for cortisol will be calculated using trapezoidal approximation with the samples 
obtained at time zero (T0) to the last measurement (T24m). Analysis will adjust for baseline cortisol levels 
by subtracting the rectangle defined the baseline sample and total observation time (T24min) from the total 
area under the curve, thus, it is possible to have negative rAUC values if cortisol levels decline below 
baseline.91 A generalized linear regression model will be conducted with rAUC as the dependent variable 
and race (AA/Black, white) as the between-subjects factor. The effects of nicotine metabolism rates, 
nicotine dependence, and cigarettes smoked per day will be examined in analysis of covariance that 
include rAUC as the dependent variable and race as the between-subjects variable. The extent to which 
cortisol changes are blunted will be determined by calculating the difference between the first and last 
cortisol assessment during the TSST.90 Cortisol values that do not change over time or those that are 
closer to zero will be considered blunted.30 Similar regression models will be used to test for racial 
differences in cortisol levels at each timepoint following exposure to an acute laboratory stressor, the 
proportion who smoke after the TSST, and scores for cigarette craving. A random effect will be added to 
the statistical models to allow for differences in participants recruited from different cites (MUSC and VCU). 
Models will be adjusted for known and potential confounders (e.g., nicotine metabolism rates). 
 
Aim 2. Evaluate racial differences in daily cortisol patterns between AA/Black and white male 
smokers. Hypotheses: AA/Black smokers will be more likely than white smokers to have blunted daily 
DCS. Compared to white smokers, AA/Black smokers will have lower absolute cortisol values during the 
waking day. This aim will examine racial disparities in cortisol responses between AA/Black and white male 
smokers in their neighborhood and community settings at 4- and 8-weeks after the TSST has been 
completed. Changes in cortisol levels will be the primary outcome variable and will be measured at multiple 
critical timepoints during the waking day. 
 
Sample Size and Power Calculations: A sample size of 50 AA/Black (Mean DCS=0.12, SD=0.15) and 50 
white (Mean DCS=0.26, SD=0.30) males achieves 84% power to detect a difference of 0.14μg/dL between 
the 2 groups with a significance level of 0.05 using a two-sided two-sample t-test, assuming similar 
differences between the groups at 4 and at 8 weeks of follow-up. This sample size would also provide 83% 
power to detect a difference of 0.13 μg/dL in absolute cortisol value between AA/Black (mean=0.35, 
SD=0.19) and white (mean=0.48, SD=0.35) males with a significance level of 0.05 using a two-sided two-
sample t-test.  
 
Statistical Analysis: A similar approach to Specific Aim 1will be used to examine racial differences in daily 
cortisol levels. Racial differences in mean cortisol levels at 4 weeks will be modeled by a generalized linear 
model similar to Specific Aim 1 with the addition of a repeated statement to account for the multiple 
measures takes for each participant throughout the day and a random intercept to allow for individual 
differences. The same will be done at 8 weeks post TSST. Models will include race and time-of-day as 
fixed effects and the interaction between them. Model-based contrasts will be used to conduct group 

Version 1; Version Date: 11/9/2021 
 
Page 10 of 14 
 
comparisons based on the fitted model. Blunted cortisol DCS will be defined similarly as in Specific Aim 1. 
Generalized linear models will be used to examine racial differences in blunted DCS at each post-TSST 
assessment. Similar models will examine the relationship between blunted DCS (at 4 and 8 weeks post-
TSST) and baseline measures of smoking behavior (e.g., smoking history, nicotine dependence, nicotine 
metabolism rates), and stressors (chronic SES stressors, psychosocial stressors, and 
structural stressors). 
 
Aim 3: Identify factors that are important to acute and daily stress responses among AA/Black and 
white male smokers by examining acute and daily cortisol patterns based on exposure to chronic 
stressors.  Hypotheses: Acute and daily cortisol responses will be associated with chronic stressors such 
that men who have greater exposure to SES, structural, and psychosocial stressors will have blunted acute 
and daily cortisol patterns. The relationship between acute and daily cortisol patterns, nicotine metabolism, 
and nicotine dependence will also be explored.  
 
Sample Size and Power Calculations: It is hypothesized that men who have a higher nicotine addiction 
(daily versus non-daily or higher FTND score versus lower) will have higher cortisol levels. A sample size 
of 100 males achieves 82% power to detect a ratio of 1.25 (25% higher cortisol levels among the highly 
addicted) when the ratio under the null hypothesis is 1 and the coefficient of variation on the original scale 
is 0.4 with a significance level of 0.05 using a two-sided two-sample t-test.  
 
Statistical Analysis: Similar to Specific Aims 1 and 2, Specific Aim 3 multivariable generalized linear 
regression models will be used to identify factors that are important to acute (baseline) and daily (4 and 8 
weeks post-TSST) stress responses (cortisol patterns). Independent associations between blunted cortisol 
responses and race, smoking behaviors, nicotine dependence at baseline, SES, and psychosocial and 
structural stressors will be evaluated. 
 
10.2 Data Storage and Privacy Protection. The data management system for the study will be designed 
to achieve the major elements of the study including: (1) determination of study eligibility, (2) monitoring 
recruitment and accrual, (3) generation of study materials, and (4) storage of data from telephone 
interviews and laboratory assessments. All data collected as part of this study will be stored on a MUSC-
based secure password-protected network server. Moreover, access to the server will be monitored by the 
PI and limited to pertinent study personnel. 
 
We will take extensive precautions to protect the privacy of the participants. Personal health identifiers 
(e.g., name, address) will not be used to identify participants in study databases or on laboratory materials. 
We will use a confidential subject identification number to identify all participant data in research databases 
and on study documents (e.g., baseline telephone assessments), and laboratory materials (i.e. clinic flow 
sheets, biospecimen tubes). Cortisol saliva kits and other biospecimen collection tubes will be labeled with 
the study identification number. A key containing each participant's name, study identification number, and 
telephone number will be kept on a secure, password-protected database on a MUSC network server until 
study procedures have been completed and the data have been checked for completeness and accuracy. 
At that time, this identifying information will be destroyed. Thus, we will retain no identifying information in 
the study data files. Moreover, all computerized study databases for clinical and questionnaire data will be 
housed on a secure, password-protected network server. All personal contact information will be kept in a 
database that will be housed separately from the database containing questionnaire data. There will be 
limited access to study files and study databases throughout the duration of the study; only pertinent study 
staff will have access to study information. 
 
All MUSC data including biospecimens, social determinants of health, clinical data, and sociodemographic 
data will be de-identified before being sent to the TRACER VCU centralized database that will be the 
repository for all TRACER-affiliated projects. The centralized database will ensure data harmonization, 
uniformity, quality control and privacy. VCU TRACER investigators will be responsible for abiding to HIPPA 

Version 1; Version Date: 11/9/2021 
 
Page 11 of 14 
 
compliance, and compliance with federal and local regulations.  Data will be collected in REDCap 
instruments to facilitate data integration into the centralized database.  
Handling Incidental Findings and Adverse Effects. In the event of any unexpected events related to 
incidental findings, safety concerns, and adverse effects, the PIs and/or study staff will contact the MUSC 
and VCU IRBs to discuss appropriate action. 
 
11.0 
Risks to Subjects 
 
Potential Risks. There is a slight risk that participants may experience adverse psychological reactions 
such as anxiety or stress as a result of discussing smoking behaviors, personal health behaviors, and 
social and psychological stressors during the screening and baseline telephone interview. We will 
minimize this risk by ensuring that telephone interviewers are trained to detect increased anxiety and how 
to intervene accordingly. Also, participants will be given rest breaks as needed throughout the telephone 
interviews, and if warranted, any referrals for follow-up psychological care will be made as needed. 
 
Participants may also potentially experience a loss of privacy as a result of providing information about 
their past medical history and personal health behaviors. However, we are using items that have been 
tested and validated and are commonly used in clinical settings and it is likely that participants would have 
been exposed to similar types of questions through their routine medical care. Therefore, we do not 
anticipate that participants will feel that their privacy has been violated. Also, we will obtain permission 
from the IRB to obtain informed consent over the telephone prior to initiating any study activity. Eligible 
participants will be required to verbally agree to participate in the study during the initial scripted telephone 
call after the invitations letters have been mailed out. Only participants that express interest in 
participating will be administered the baseline telephone interview. Written informed consent will be 
obtained prior to conducting the laboratory assessments. We will also give participants the option to opt 
out of being contacted if they do not want to be contacted about participating in the study. Participants 
will be informed that their participation is voluntary and that they can withdraw their participation at any 
time without any adverse consequences. 
 
There are also minimum risks associated with the laboratory assessments. Participants may experience 
some mild physical discomfort from the biospecimen collection (e.g., saliva swab) at the laboratory visits.  
Participants will also be exposed to a psychological stressor (giving a speech and arithmetic task) to induce 
a stress response. It is likely that the stress test will produce a certain amount of stress and may cause an 
increase in blood pressure and increased heart rate. We do not anticipate that the laboratory stressor 
would provoke any significant adverse reactions that are not usually encountered on a day-to-day basis. 
The Research Assistant conducting the in-person laboratory assessment will be highly trained in 
administering the laboratory stress test. As part of this training, she/he will be trained to determine if 
participants are experiencing any adverse reactions and will terminate the assessment immediately. If 
warranted, referrals for follow-up psychological care will be made as needed. Our study team includes a 
Clinical Psychological (Carla Kmett Danielson, PhD) who has extensive experience administering the Trier 
Social Stress Test (TSST), monitoring responses, and making referrals to psychological services as 
needed. 
 
Protection Against Risks. We will take every precaution to protect the privacy and autonomy of 
participants and to assure that the consent is truly informed. As we described above, verbal informed 
consent will be obtained for screening, study enrollment and completion of the baseline and follow-up 
assessments. As part of the verbal informed consent process, the purpose of the study will be explained 
orally and the right to refuse to answer all or some of the questions will be emphasized. It will also be 
stressed that they can start or stop their participation at any time throughout the duration of the study. 
Participants who refuse to complete the laboratory assessment or those who withdraw from the study will 
be thanked and all further contacts will be terminated.  
 

Version 1; Version Date: 11/9/2021 
 
Page 12 of 14 
 
We will obtain written informed consent prior to conducting the laboratory assessments. As part of 
obtaining written informed consent, we will review the purpose, procedures, duration of participation, and 
their rights for being a research participant. Participants will be given the opportunity to ask questions 
before signing the informed consent form and proceeding with the laboratory assessments. 
 
To protect the privacy of participants that provide permission to donate biospecimens for future use, 
biospecimens will be given a coded number and stored based on that code. This coded number can be 
linked back to limited personal health information and other clinical and social data pertaining to them. Any 
information learned from this study in which you might be identified will be confidential and disclosed only 
with their permission. Every effort will be made to keep any information collected about the study 
participants confidential. Study investigators will adhere to compliance and ethical conduct of research 
procedures to protect the privacy and welfare of participants.   
 
We will also take extensive precautions to protect the privacy of the participants. Personal health 
identifiers (e.g., name, address) will not be used to identify participants in study databases or on 
laboratory materials. We will use a confidential subject identification number to identify all participant data 
in research databases and on study documents (e.g., baseline telephone interview), and laboratory 
materials (i.e. biospecimen tubes). Cortisol saliva kits and plasma tubes will be labeled with the study 
identification number. A key containing each participant's name, study identification number, and 
telephone number will be kept in a secured location until study procedures have been completed and the 
data have been checked for completeness and accuracy. At that time, this identifying information will be 
destroyed. Thus, we will retain no identifying information in the study data files. Moreover, all 
computerized study databases for questionnaire data will be housed on a secure, password-protected 
network server. All personal contact information will be kept in a database that will be housed separately 
from the database containing questionnaire data. There will be limited access to study files and study 
databases throughout the duration of the study; only pertinent study staff will have access to study 
information. 
 
12.0 
Potential Benefits to Subjects or Others 
 
There are no direct clinical benefits to participating in this study. The potential risks associated with study 
participation are minimal and the information that is learned through this research is likely to have 
significant benefits. Racial disparities exist as it relates to smoking cessation outcomes among AA/Black 
smokers. Observational studies have shown that psychosocial stress is a potential intervention target for 
smoking cessation treatment programs. Therefore, evaluating racial differences in biological pathways 
involved in stress reactivity and nicotine addiction would provide empirical evidence necessary for 
designing precision medicine strategies for tobacco control interventions that address the smoking patterns 
and cessation needs among racial minorities and individuals from other medically underserved groups. 
 
Importance of Knowledge to be Gained. Cigarette smoking continues to be a leading cause of morbidity 
and mortality from lung cancer and other chronic diseases among adults in the US. Data from national 
studies continue to expose the disparities that exist among AA/Black smokers as it relates to poorer 
smoking cessation rates, unfavorable socioeconomic factors, and greater levels of perceived stress that 
impact tobacco use. This study will be the first to examine the complex ways in which psychological, 
behavioral, and biological pathways contribute to NMR and smoking behaviors among AA/Black and white 
smokers. Our research will move beyond black-white comparisons in smoking behaviors and cessation 
rates by taking a biobehavioral results of this research will provide greater insights into behavioral, 
psychological, and biological mechanisms that contribute to racial disparities in smokers and will generate 
novel empirical data that can be translated into targeted interventions to reduce racial disparities in 
smoking behaviors and improve tobacco control outcomes. 
 
Additionally, this study will support the collection, analyses, and storage of biospecimens (saliva, urine) 
from a racially and ethnically diverse sample of smokers. Biospecimens from a racially diverse sample in 
addition to collected data on social determinants of health and other biological and clinical data will help 

Version 1; Version Date: 11/9/2021 
 
Page 13 of 14 
 
with enhancing our understanding of factors related to smoking disparities and enable investigators to 
conduct studies that address multilevel determinants of cancer risk and outcomes. 
 
 
 
 
 
 

Version 1; Version Date: 11/9/2021 
 
Page 14 of 14 
 
13.0 
Sharing of Results with Subjects 
The results of this study will not be shared with participants or their physicians. Research results will not 
be placed in participant’s medical charts.