Clinical trial NCT03580525
Conditions: Nicotine Dependence
Sponsor: Yale University
Start date: 2019-02-14; Completion date: 2020-11-19
Enrollment: 24 participants; Allocation: RANDOMIZED; Intervention model: CROSSOVER

Brief summary:
A placebo-controlled study to enroll male and female tobacco smokers who will participate in five experimental sessions. subjects will be given an IV infusion of either saline or 1 mg nicotine at rapid, moderate or slow infusion rates (nicotine at 0.24,0.096, 0.048 and 0.024, mcg per kg body weight per sec).

Detailed description:
A placebo-controlled study that will enroll male and female tobacco smokers' menthol to participate in five experimental sessions. During the experimental session, subjects will be given an IV infusion of either saline or 1 mg nicotine at rapid, moderate or slow infusion rates (nicotine at 0.24,0.096, 0.048 and 0.024, mcg per kg body weight per sec). The infusion conditions for each experimental session will be determined in random order. Aim 1 is to establish a dose-effect curve for positive subjective effects (drug liking and good drug effects) and alleviation of smoking urges, as a function of nicotine delivery rate in menthol and non-menthol cigarette preferring smokers Aim 2 is to establish a dose-effect curve positive subjective effects and alleviation of smoking urges as a function of nicotine delivery rate. Aim 3 is to establish a dose-effect curve for nicotine's effect to alleviate symptoms of nicotine withdrawal in abstinent smokers as a function of nicotine delivery rate. Aim 4 is to establish a dose-effect curve for nicotine's acute cardiovascular health effects. Data from this project will help to establish benchmark values for nicotine's threshold effects that will guide policies on the nicotine yield of tobacco products. Presented is the time frame at which the peak change was strongest by treatment arm. The possible peak numbers could be 1, 3, 5, 7 and 10 minutes."

Arms: arm 1: 0.00 mcg/kg/s The day order will be randomized per day arm 2: 0.24mcg/kg/s The day order will be randomized per day arm 3: 0.096mcg/kg/s The day order will be randomized per day arm 4: 0.048mcg/kg/s The day order will be randomized per day arm 5: 0.048mcg/kg/s The day order will be randomized per day
Interventions: intervention 1: Nicotine saline infusion 0.00mcg/kg/s intervention 2: Nicotine infusion 0.24mcg/kg/s intervention 3: Nicotine infusion 0.096mcg/kg/s intervention 4: Nicotine infusion 0.048 mcg/kg/s intervention 5: Nicotine infusion 0.024mcg/kg/s
Intervention descriptions: intervention 1: saline 0.00mcg/kg/s intervention 2: nicotine 0.24mcg/kg/s intervention 3: nicotine 0.096mcg/kg/s intervention 4: nicotine 0.048mcg/kg/s intervention 5: nicotine 0.024mcg/kg/s

Protocol documents:
Prot_SAP_000.pdf: 
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1. Principal Investigator: Mehmet Sofuoglu, M.D., Ph.D. 
2. Co-Investigators While all research staff are trained to provide informed consent, those 
identified with an asterisk (*) will provide informed consent for this study. All the research staff 
will have access to the PHI 
Co- Investigator: Kevin Jensen, Ph.D., Elise E. DeVito, Ph.D., Joel Gelernter, M.D.,  Suprit 
Parida, M.D. 
Nursing Staff: *Ellen Mitchell, RN, Angelina Genovese, R.N., Elizabeth O’Donnell, R.N., Jane 
Weiner, R.N. 
Research Staff: *Lance Barnes, *Stacy Minnix, BSW, and *Chris Cryan 
 
3. Title of Project: Nicotine Delivery Rate and Its Abuse Potential: Impact of Menthol 
 
4.  Purpose, hypothesis and key questions: 
The FDA can regulate tobacco products to reduce their harmful effects and to limit their 
addictive potential. Benowitz and Henningfield proposed that gradually reducing the nicotine 
content of cigarettes to an amount below the addictive threshold could prevent the development 
of addiction (1). More recently, Shihadeh and Eissenberg made a similar proposal for 
minimizing the addictive potential of electronic cigarettes (EC) (2). After considering several EC 
variables, the nicotine delivery rate, or “nicotine flux”, was considered by Shihadeh and 
Eissenberg as the most critical factor for evaluating the abuse potential of a given EC(2). An EC 
with low nicotine flux might have low abuse potential and minimal negative health effects; in 
contrast, an EC with high nicotine flux might have high abuse potential and high risk for causing 
negative health effects. Indeed, newer generation ECs that deliver nicotine rapidly are rated as 
more satisfying compared to older generation ECs that deliver nicotine slowly (3), suggesting 
that higher flux ECs might have greater abuse potential. However, the nicotine delivery rate 
that is essential for the addictive effects of nicotine has yet to be empirically determined by 
carefully controlled human studies.  
The primary aim of this project is to establish a dose-effect curve for nicotine reinforcement as 
a function of nicotine delivery rate. We will use the dose-effect curve to estimate a threshold 
delivery rate for reinforcement.  IV nicotine, in contrast to ECs, can deliver precise, reproducible 
dosing, which is necessary for accurately assessing dose-response and threshold effects. The 
estimated threshold for reinforcement will establish a benchmark for evaluating the addictive 
potential of ECs and other inhaled nicotine products.  
Specific Aim:  To determine the dose-effect curves for positive subjective effects (drug liking and 
good drug effects) and alleviation of smoking urges, as a function of nicotine delivery rate in 
menthol and non-menthol cigarette preferring smokers.  
Hypothesis #1A: Positive subjective effects of nicotine will gradually decline with slower 
delivery rates, with minimal effects of nicotine delivery rate on urges to smoke.  
Hypothesis #1B: Non-menthol smokers, compared to menthol smokers, will have greater 
responses to nicotine for these outcomes as reflected by a leftward shift in dose-effect curves. 
 
Exploratory Aim #1: To explore the dose-effect curves of nicotine delivery rate for a) 
reinforcement (assessed with the monetary value of the dose from the Multiple-Choice Procedure 
(6), b) heart rate and blood pressure, and c) tobacco withdrawal severity (assessed with self-
report symptoms and cognitive performance).  


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Exploratory Aim#2: To examine the impact of plasma nicotine levels and rate of nicotine 
metabolism (measured by plasma hydroxycotinine/cotinine ratio) on the dose-effect curves for 
the main study outcomes.  
Exploratory Aim#3: To examine sex differences for the main study outcomes. 
 
5. Background: 
Nicotine control policies to reduce the addictive potential of tobacco products:  
Benowitz and Henningfield (1) proposed that the gradual reduction of nicotine in cigarettes to an 
amount below the addiction threshold could prevent the development of nicotine addiction 
among young smokers. The Benowitz and Henningfield proposal and its subsequent appraisal by 
the American Medical Association Council on Scientific Affairs (6) have provided the 
foundation for the current nicotine control approaches being considered by the FDA (7).  More 
recently, Shihadeh and Eissenberg made a similar proposal for minimizing the potential risks of 
using EC (2). After considering several EC variables including liquid composition, puff behavior 
and electrical power, they focused on nicotine flux, the rate of nicotine delivery, as the key factor 
in determining the abuse potential of a given EC. Accordingly, an EC yielding no nicotine flux 
will not maintain usage. In contrast, an EC with high nicotine flux may have high addictive 
potential and lead to negative health effects. If the nicotine flux does not produce dependence but 
is sufficient to attenuate craving for cigarettes and withdrawal symptoms among those that are 
already dependent, the product may have limited abuse potential while retaining potential 
benefits (e.g. as a smoking cessation aid). In the “nicotine flux” model, the delivery rate of 
nicotine, rather than the amount of nicotine in the products, is more likely to reflect the addictive 
potential of the product. The proposed central role of nicotine flux in determining the addictive 
potential of nicotine remains to be tested in controlled human studies. Policies to reduce the 
addictive potential of tobacco product would be strengthened if the thresholds for nicotine’s 
addictive properties were empirically defined by carefully controlled studies. 
Nicotine pharmacokinetics: Cigarette smoking and EC use: 
Among nicotine delivery products, cigarette smoking produces the most rapid delivery of 
nicotine to the brain (10 to 20 sec) and has the highest abuse potential. The peak nicotine 
concentrations in blood, ~15 ng/ml, occur approximately 5 minutes after starting to smoke a 
cigarette (4). The pharmacokinetics of nicotine delivered by EC devices was characterized in a 
recent study. 
 The peak nicotine concentration in blood, ~8 ng/ml, was approximately 12 minutes after the 
initiation of 15 puffs, with one puff every 30s (5). ECs deliver nicotine slower than tobacco 
cigarettes, probably because EC vapor does not penetrate as deeply into the lung tissue as 
cigarette smoke for most users. High “nicotine flux” ECs can overcome some of these 
limitations, so that nicotine is delivered at a rate that is closer to the rate of delivery from tobacco 
cigarettes. Indeed, newer generation ECs that deliver nicotine more rapidly are rated as more 
satisfying compared to older generation ECs that deliver nicotine slowly (3). 
Nicotine pharmacokinetics: IV administration protocols to study nicotine reinforcement: 
Nicotine administered by IV infusion can be carefully modulated to resemble the nicotine intake 
from tobacco product use.  For example, Rose et al. showed that the pharmacokinetics of 
nicotine delivered by IV infusion resembles the pharmacokinetics of nicotine delivered via 
cigarette smoking (8). In this study, the arterial plasma nicotine concentrations from smoking 
one cigarette was first determined for each subject, then the equivalent dose of nicotine was 
delivered by IV infusion over a similar time course as smoking a cigarette. Both smoking and IV 
infusion produced similar arterial (20.5 vs. 20.4 ng/ml) and venous (6.9 vs. 7.8 ng/ml) plasma 
concentrations of nicotine. The rapid time to peak arterial nicotine concentrations following 
smoking was also observed for IV infusion (8). Multiple studies have demonstrated that rapid IV 
nicotine infusion (i.e., less than 60 seconds) elicits positive drug effects (e.g., good effects and 


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drug liking) similar to smoking, and reinforcing effects (i.e., self-administration) in dependent 
adult smokers (9-13).  
Because cigarette smoke and EC vapor contain many compounds in addition to nicotine and the 
amount of nicotine delivered via smoking or EC puffing cannot be reliably controlled in an 
experimental setting, cigarettes and ECs are not suitable tools for examining dose-dependent 
effects of nicotine on reinforcement (14-17).  It is also important to note that the IV infusion 
protocol models the nicotine delivery of tobacco products in the absence of sensory stimuli (e.g. 
taste, olfactory or visual stimuli) that are present in tobacco products, including cigarettes (and 
EC) with modified nicotine levels. In contrast to other nicotine delivery systems, IV infusion can 
deliver precise and reproducible dosing, which is crucial for systematically examining the 
relationship between nicotine delivery rate and nicotine’s effects in humans.  
 
Preliminary Studies: 
IV nicotine infusion protocols to study the addictive properties of nicotine in humans 
We have developed IV nicotine infusion protocols to answer key questions regarding the 
addictive properties of nicotine and individual differences in tobacco smoking behavior that are 
mediated by nicotine (12, 18-21). Subjects in Fig 1 were 187 adult male and female dependent 
smokers that had abstained from smoking for ~10 h (adapted from Jensen KP et al. 2015)(19). 
The average age was 36 years (SD = 8.9).  Subjects received infusions of saline and doses of 
nicotine at 0.12 and 0.24 mcg/kg/second for 60s (0.5 and 1 mg nicotine per 70 kg body weight 
doses) in uniform order. The doses of nicotine delivered in this session approximate the total 
dose of nicotine delivered by smoking 0.5 and 1.0 tobacco cigarettes. Fig 1 shows the subjective 
ratings of pleasurable and aversive effects after IV saline and nicotine infusion (19). IV nicotine 
increased ratings of pleasurable effects (main effect for dose: F (2,3025) = 124.7, P< 0.01), while it 
had a more subtle effect on ratings of aversive effects (main effect for dose: F (2,3025) = 1.85, P= 
0.16). Fig 1c shows that nicotine withdrawal symptoms (M-NWS total score), the urge to smoke 
for reward (BQSU factor 1), and the urge to smoke to reduce negative symptoms (BQSU factor 
2) were lower at the end of the IV nicotine infusion session relative to overnight-abstinence 
baseline (main effect of time for MNWS: F (1,188) = 64.85, P < 0.01; BQSU Factor 1: F (1,184) = 
116.6, P < 0.01; BQSU Factor 2: F (1,184) = 66.6, P < 0.01). Withdrawal symptoms were assessed 
by the Minnesota Nicotine Withdrawal Scale (M-NWS) and Brief Questionnaire on Smoking 
Urges. 
 
Fig 1. IV nicotine infusion to study the addictive properties of nicotine. IV 
nicotine induces (A) positive and (B) negative subjective effects and (c) 
suppresses nicotine withdrawal symptoms.  n=187, dependent smokers, ** 
p<0.01, *p=0.16. (Jensen et al. Neuropsychopharmacology, 2015) 
 


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Summary of preliminary studies: 
• We have developed IV nicotine infusion protocols to answer key questions regarding the 
addictive properties of nicotine and individual differences in tobacco smoking behavior that 
are mediated by nicotine (12, 18-20, 22). 
• IV nicotine doses infused at 0.12 and 0.24 mcg/kg/second for 60s (~0.5 and 1 mg doses) 
induce pleasurable (“drug liking”, “feels good”) drug effects, aversive drug effects and 
suppresses withdrawal symptoms (Fig 1), similar to smoking. 
• Establishing a dose-response curve for nicotine reinforcement as function of nicotine 
delivery rate and estimating a threshold rate for reinforcement with the IV nicotine infusion 
protocol developed in this proposal is feasible. 
 
6. Significance: 
Nicotine is considered to be the main addictive ingredient in tobacco. Therefore, the nicotine 
content of tobacco products serves as a logical target in the development of effective tobacco-
control policies. In an influential article, Benowitz and Henningfield proposed that the gradual 
reduction of the nicotine content of cigarettes to an amount below an addictive threshold could 
prevent the development of nicotine addiction among young smokers. More recently, a similar 
addictive threshold was proposed for electronic cigarettes (EC) based on their rate of nicotine 
delivery. Accordingly, if an EC delivers nicotine at rates above certain, yet undetermined 
threshold, they can be addictive and potentially harmful, especially in nicotine naïve users. In 
contrast, if the nicotine delivery rate of an EC is below a critical threshold, it may have low 
addiction liability but provide sufficient nicotine delivery to help smokers quit smoking by 
alleviating urges to smoke and reducing tobacco withdrawal symptoms. This proposed critical 
rate of delivery that underlies the addictive effects of nicotine, however, has yet to be empirically 
validated by controlled human studies. This knowledge gap is partly due to the difficulty in 
accurately controlling the rate of nicotine delivery with currently available nicotine delivery 
products like tobacco cigarettes or EC. To close this knowledge gap, we propose to use 
intravenous (IV) nicotine administration because the rate of nicotine exposure by the IV and 
inhaled routes are comparable. IV nicotine administration also allows for accurate dosing over a 
wide range of delivery rates.  
 
 
7. Subjects: 
One hundred smokers will be recruited from the New Haven area through newspaper, and radio 
advertisements and fliers. The study will be described over the telephone. Subjects will be given 
a brief tobacco use history and medical screening questionnaire. Eligible subjects will be invited 
to a single screening evaluation. The screening evaluation will include the following: a) 
obtaining an informed consent; b) tobacco use history via the Fagerstrom Test of Nicotine 
Dependence (FTND) and DSM-5 Tobacco Use Disorder (TUD) criteria; d) urine cotinine levels 
determined with a NicAlert test strip (info: www.nymox.com/default.action?itemid=47).  If 
subjects are eligible they will be invited to participate in a second evaluation, which will include: 
a) complete physical and psychiatric examination including the structured clinical interview 
(SCID) for DSM-5 criteria; b) a complete physical and laboratory examination including CBC, 
TSH, ALT, AST, GGT, alkaline phosphatase, glucose, BUN and creatinine; c) urine analysis for 
drug screening, and for women, urine pregnancy test; and d) ECG 


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Inclusion criteria: 1) Female and male smokers, aged 18 to 35 years, who have been  smoking 
tobacco cigarettes for at least a year; 2) smoke ≥ 5 and less than 20 cigarettes per day; 3)  urine 
cotinine levels > 100 ng/mL consistent with nicotine intake of an active smoker (23); 4) not 
seeking treatment at the time of the study for nicotine dependence; 5) in good health as verified 
by medical history, screening examination, and screening laboratory tests; and 6) for women, not 
pregnant as determined by pregnancy screening, nor breast feeding, and using acceptable birth 
control methods.  
Exclusion criteria: 1) history of major medical or psychiatric disorders that the physician 
investigator deems as contraindicated for the subject to be in the study; 2) regular use of 
psychotropic medication (antidepressants, antipsychotics, or anxiolytics); 3) current alcohol or 
substance dependence for any other recreational or prescription drugs other than nicotine; 5) use 
of e-cigarettes more than 10 days in the past 30 days; 6)  urine drug screening indicating recent 
illicit drugs use (with the exception of marijuana). 
Justification for age criteria: The study will enroll young adults between the ages of 18 to 35 to 
minimize variation in the number of years of smoking that can influence measures of dependence 
including withdrawal severity (24, 25).   
Justification to include smokeless tobacco and e-cigarette users: We will include users of 
smokeless tobacco or e-cigarettes given the high prevalence of e-cigarette and smokeless tobacco 
products among young adults (26-28). As noted above, urine cotinine will be used to 
biochemically confirm the subjects’ nicotine consumption and smoking status and used as a 
covariate in all analyses if required. 
Subject sampling to account for sex, race, dependence symptoms, and smoking frequency: We 
are planning to enroll Caucasian and African-American smokers while maintaining an 
approximately equal male-to-female ratio.  
We will create dichotomous variables to be used as a covariate to match groups on race 
(European American and African American) and sex because of the potential influence of race 
and sex on smoking behavior and nicotine pharmacokinetics (22, 29). We will also control for 
differences in the frequency of smoking because it may influence the behavioral effects nicotine 
(30-32); a continuous variable based on the reported smoking frequency (cigs per day) will be 
used as a covariate in the analyses if required.  
8: Recruitment:  
Hundred subjects will be recruited. The goal is to have 70 completers, 35 menthol and 35 non-
menthol cigarette smokers. 
9. Research Plan: 
A. Overview 
Experimental Summary: Subjects will complete five separate experimental sessions on five 
separate days with each session beginning around 8 AM (Fig 2). Each session (1 to 15 days 
apart) will include one infusion condition that will be either saline or nicotine at four different 
infusion rates. The five infusion conditions will be assigned randomly to one of the five 
experimental sessions. All infusions will last 10 minutes and be controlled by two infusion 
pumps, a saline infusion pump and a nicotine infusion pump.  The 0.24 mcg/kg/s condition will 
include a 1 minute  infusion of nicotine followed by a 9 min infusion of saline; the 0.096 
mcg/kg/s condition will include a 2.5 minute infusion followed by a 7.5 min infusion of saline; 
the 0.048 mcg/kg/s condition will include a 5 min infusion of nicotine followed by a 5 min 
infusion of saline; the 0.024 mcg/kg/s condition will include a 10 min infusion of nicotine and no 
infusion of saline; and the placebo condition will include a 10 min infusion of saline and no 


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infusion of nicotine. The most rapid nicotine infusion rate, 0.24 mcg/kg/s, has proven to be well 
tolerated in our prior studies (12, 18-20, 22). The total weight-adjusted nicotine dose will not 
exceed 1.2 mg. Subjects will complete baseline assessments after an indwelling catheter is 
inserted into an antecubital vein for safety and drug administration. Immediately prior to the start 
of the infusion (@ min 0) and at intervals following the start of the infusion, heart rate, blood 
pressure, DEQ and withdrawal assessments will be taken as shown in Fig 2.  At the end of the 
session (min 120), subjects will complete the Drug versus Money Multiple-Choice Form 
($MCP) (23). 
Session procedures:  Before the experimental session, subjects will be required to abstain from 
smoking for 10h, which will be verified by expired air CO levels ≤ 10 ppm (33, 34). Subjects 
will also be asked to refrain from consuming alcoholic beverages and drugs prior study 
participation, which will be verified by urine drug screening and breathalyzer before the 
sessions. Subjects that are non-compliant will be rescheduled or, if they are repeatedly non-
compliant, discharged from the study. Subjects will be instructed to drink their typical amount 
of caffeinated beverages to minimize caffeine withdrawal, which could confound the study 
measures. Subjects will be instructed not to eat for 4 h before the sessions to minimize 
heartburn or nausea that can be associated with IV nicotine administration. A light meal will be 
provided at the end of each session.  
Fig # 2 Schedule of Events: Experimental Session* 
Time point Measures and Events 
Baseline 
CO, urine and blood samples, HR/BP, M-NWSC, BQSU, SAFTEE, CPT 
0 min  
IV Infusion starts 
1 min 
HR/BP, DEQ, plasma nicotine 
3 min 
HR/BP, DEQ, plasma nicotine  
5 min 
HR/BP, DEQ, plasma nicotine  
8 min 
HR/BP, DEQ, plasma nicotine 
10 min 
IV Infusion ends, plasma nicotine 
11 min 
HR/BP, DEQ, BQSU, plasma nicotine  
12 min 
HR/BP, plasma nicotine  
13 min 
HR/BP, DEQ, plasma nicotine  
15 
HR/BP, DEQ, plasma nicotine  
18  
HR/BP, DEQ, plasma nicotine  
20  
HR/BP, DEQ, plasma nicotine  
25  
HR/BP, DEQ, 
30 min 
HR/BP, DEQ, BQSU, CPT, M-NWSC 
40 
HR/BP, DEQ, plasma nicotine 
50 
HR/BP, DEQ, plasma nicotine 
60  
HR/BP, DEQ, BQSU, M-NWSC CPT, plasma nicotine 
90  
HR/BP, DEQ, BQSU, M-NWSC CPT, plasma nicotine 
120 min 
End of session, HR/BP, DEQ, plasma nicotine, M-NWSC, BQSU, SAFTEE, CPT 
180 min 
Discharge  
*Saline infusions will follow each nicotine infusion to maintain a 10 min total infusion time for 
each experimental session. Abbreviations: CO: Alveolar carbon monoxide; HR/BP: Heart 
rate/Blood pressure; M-NWSC: Minnesota Nicotine Withdrawal Symptom Checklist; BQSU: 


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Brief Questionnaire of Smoking Urges; CPT: Continuous Performance Test; DEQ: Drug Effects 
Questionnaire; SAFTEE: Systematic Assessment for Treatment Emergent Events. 
 
 
 
 
B. Medical Monitoring And Safety 
Subjects will be given a thorough physical examination as part of the post-consent screening 
procedures. For nicotine administration sessions, a physician or a nurse will present be and 
subjects will be attached to a cardiac monitor as well as a blood pressure and heart rate 
monitoring device. One IV catheter will be in place in each arm or only one if two IV’s can’t be 
placed.  Subjects will be administered nicotine only if the systolic blood pressure is < 150 mmHg 
and heart rate is < 90 beats/minute. The procedures will terminate if blood pressure at any time is 
>170/110 mm Hg, the heart rate is >130 beats/min, or if they develop signs and symptoms of 
nicotine toxicity. Subjects will remain in the laboratory for at least an hour after the experimental 
infusion administration. These procedures have been developed as part of our IND application 
for IV nicotine. 
 
C. Measures  
C.1 Intake Measures  
1) Fagerstrom Test of Nicotine Dependence (FTND): This self-report measure assesses the 
degree of nicotine dependence and has been used widely in smoking studies (Heatherton et al., 
1991)  
2) Center for Epidemiologic Studies Depression (CES-D) scale: The CES-D is a 20-item self-
report measure of depressive symptoms (35). This scale will be used at intake to control for 
baseline differences in depressive symptoms. 
3) The Holmes-Rahe Life Stress Inventory (HRLSI): This is a self-report measure of 43 
common life events related with some degree of stress on an individual's life. The scale was 
developed by the psychologists T.J. Holmes and R.  Rahe, who reported that serious physical 
disorders, such as myocardial infarction, peptic ulcer, infections, and a variety of psychiatric 
disorders were positively associated with the number of life stressors scale within a period of 1 
year. This scale will be used at intake to control for baseline differences in life stress. 
4) PTSD Checklist for DSM-5 (PCL-5): The PCL-5 is a 20-item self-report measure that 
assesses the 20 DSM-5 symptoms of PTSD(36). This scale will be used at intake to control for 
baseline differences in PTSD symptoms 
 
C.2 Study outcome measures 
1) Physiological:  
1.1 Heart rate (HR) and blood pressure (BP) readings will be taken at intake during 
screening. During the sessions HR and BP will be monitored continuously for medical/safety 
reasons. The HR and BP responses will help us determine the effect of delivery rate on some of 
the acute cardiovascular health risks associated with nicotine (36). In our preliminary studies, the 
peak effect of nicotine versus saline has a large effect size.  We will analyze the peak effect 


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(determined from assessments at min 0, 1, 2, 4, 6, 8, 10, 12, 14, 16, 18 and 20) in our primary 
analysis because with the peak effect we have the greatest statistical power (>0.8) to detect 
infusion rate differences. Additional responses will be included in secondary analyses.   
2) Biochemical: 
2.1 Cotinine levels: Urine cotinine levels will be determined at baseline with a semi-
quantitative test strip.  
2.2 Alveolar carbon monoxide: CO readings ≤ 10 ppm will be used to verify compliance with 
overnight smoking abstinence. In our prior work we have used plasma nicotine levels to confirm 
that smokers with CO ≤ 10 ppm were overnight abstinent with exceptional concordance (95% 
had plasma nicotine < 10 ng/ml; mean = 2.8 ng/ml (SD 3.1), N=201). The 10 ppm cutoff is 
higher than cutoffs recommend for distinguishing smokers from non-smokers (~5 ppm) but 
consistent, albeit slightly more conservative, than a suggested cutoff  (12 ppm) for distinguishing 
8 h abstinent smokers from non-abstinent smokers (25). 
3) Drug reinforcement and subjective effects: 
3.1 Drug versus Money Multiple-Choice Procedure ($MCP): This procedure was developed 
and validated by Roland Griffiths and colleagues as an efficient tool to assess drug reinforcement 
in humans, including nicotine reinforcement (23, 37-39).  For each experimental session (5 
total), subjects will have choices between forfeiting or receiving escalating sums of money on a 
scale of values between -$20.00 and $20.00 or re-receiving that trial’s infusion. The monetary 
scale will include values at $0.25 increments between $2.00 and -$2.00 and values at $0.50 
increments from $2.00 to $20.00 and from -$2.00-$20.00. A crossover point, the value at which 
the subject chooses money rather than infusion, will be determined for each session.  
3.2 Subjective Drug Effects: 1) Drug Effects Questionnaire (DEQ): Smokers will rate on a 
100 mm scale, from "not at all" to "extremely, 12 items that are related to nicotine’s effect," The 
items are 1) feel the “drug strength,” 2) feel “good” drug effects, 3) feel “bad” drug effects, 4) 
like the drug effects, 5) feel high, 6) feel stimulated, 7) feel anxious, 8) feel down, 9) want more. 
This instrument is for a rapid detection of nicotine’s effects and is adapted from a VAS (40). The 
DEQ will be administered at minute 0 (pre-infusion) and at minute 1, 2, 4, 6, 8, 10, 12, 14, 16, 
18, 20, 30, 60, 120 post-infusion initiations. The timing of these measurements is based on our 
previous studies to optimally capture the physiological and subjective effects of nicotine. The 
peak effect of nicotine versus saline (e.g. Fig 1a, 1 minute post-infusion) has a large effect size. 
We will analyze the peak effect in our primary analysis because with the peak effect we have the 
greatest statistical power (>0.8) to detect infusion rate differences. Additional responses will be 
included in secondary analyses.  
3.3Cognitive Performance: CPT (Continuous Performance Test): Cognitive performance will 
be assessed with the continuous performance test (CPT) from the ANAM battery (University of 
Oklahoma): This test was chosen because of its sensitivity to tobacco withdrawal (52, 53). CPT 
assesses sustained attention, concentration, and working memory. For CPT, the main outcome 
measures will be percent correct responses and reaction time (52). 
 
4) Withdrawal syndrome symptoms: 
4.1 Minnesota Nicotine Withdrawal Symptom Checklist (M-NWSC): Smokers will be asked 
to rate several nicotine withdrawal symptoms on a 100 mm scale, from "not at all" to 


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"extremely." The items are derived from the M-NWSC (41) and have been used in previous 
human studies (42), including our own (18-20, 43).  
4.2 Brief Questionnaire on Smoking Urges (BQSU): This 10-item scale, originally developed 
by Tiffany and Drobes (44), is a reliable and sensitive assessment of craving and withdrawal 
symptoms (45, 46).  
5) Measures of Dependence (Tobacco and other drugs) and Axis I psychiatric disorders: 
5.1 DSM-5 Tobacco Use Disorder (TUD) criteria will be used to assess nicotine dependence 
(yes/no).  The Fagerstrom Test of Nicotine Dependence (FTND) will be used as a second 
measure of dependence. The FTND assesses the degree of nicotine dependence on a 10 point 
scale (0-10) based on a self-report of symptoms related to heaviness of smoking, withdrawal and 
interference (47). 
5.2 Tobacco and Other Drug Use: At intake self-reports of cigarette smoking, other tobacco 
products, drug and alcohol use (cocaine, alcohol, opioids, marijuana, and other illicit drugs) will 
be assessed with Time Line Follow-Back, which is a reliable and valid instrument for monitoring 
substance use (48-50).  
5.3 Structured Clinical Interview for DSM-5 (SCID) for Axis I disorders, a semi-structured 
interview based on DSM criteria (51), will be performed to diagnose Axis I psychiatric disorders.  
6) Adverse events 
6.1 SAFTEE: In order to monitor adverse events from the study medications, the SAFTEE 
will be administered before and after each session. The SAFTEE, which has been used in a 
number of pharmacotherapy trials (52), and includes possible side effects of study medications.  
7)  Genetics 
7. 1     Blood samples for DNA extraction will be collected to examine whether any of the 
genes modify the effects of nicotine. Candidate genes will be selected from a list of genes 
hypothesized to be involved in nicotine’s effects. The current list of genes includes, but is not 
limited to, genes that encode nicotinic receptors and enzyme that metabolize nicotine. To protect 
confidentiality, each subject’s blood sample will be encoded with a numeric designation and the 
name of the individual will be stored in a separate database. The samples will be transferred to 
the Genetic Laboratory at the VA medical Center for processing and storage.   
 
D. Drugs 
Nicotine administration: Nicotine 1mg/mL solution for injection obtained from US Specialty 
Formulations LLC, Bethlehem, Pennsylvania will be prepared for IV infusion by the research 
pharmacy at the West Haven VA.  Nicotine and saline will be administered by infusion pump via 
a single IV catheter located in a forearm vein. We have followed these procedures in our 
previous studies, which were completed without any adverse effects attributed to nicotine or 
other safety concerns. Each session will include one 10-minute infusion that will be controlled 
by a combination of two infusion pumps. One infusion pump will control nicotine delivery and 
one infusion pump will control saline delivery. The infusions pumps will be operated silently and 
be toggled on and off to reach the 10-min total infusion time for the given condition. Subjects 
will be blinded to the infusion pump procedures. For this project, an amendment to Dr. 
Sofuoglu’s IND for IV nicotine will be submitted. 


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Justification for the nicotine dose and nicotine delivery rate: For this proposal, we selected one 
active dose of nicotine, 1.0 mg per 70 kg body weight, and placebo (saline). The 1.0 mg per 70 
kg body weight nicotine dose approximates the total nicotine dose delivered to a smoker when 
they smoke a typical tobacco cigarette (53).  Our previous studies of ND smokers indicates that 
1.0 mg per 70 kg body weight dose delivered in 1 min (0.24 mcg/kg/s) induces robust drug liking 
subjective effects and suppresses withdrawal symptoms. However, this dose deliver rate is faster 
than what a smoker might encounter while smoking a cigarette. The moderate delivery rates, 
0.096 and 0.048 mcg /kg/s, that approximates the rates of intake encountered while a smoker 
smokes a typical cigarette over 5 min.  The slowest nicotine delivery rate, 0.024 mcg/kg/s, was 
chosen to approximate the nicotine intake rate that an individual might encounter from a newer 
E-cig device (2,5).  The total weight-adjusted nicotine dose will not exceed 1.2 mg. 
 
10. Data analysis methods 
Hypothesis #1: To determine the dose-effect curves for positive subjective effects (drug liking 
and good drug effects) and alleviation of smoking urges, as a function of nicotine delivery rate in 
menthol and non-menthol cigarette preferring smokers. 
Positive subjective effects of nicotine will be assessed with the “Like the Drug Effects” and 
“Good Drug Effects” items from the DEQ, consistent with the FDA Guidance on abuse potential 
assessment (10). These items have been shown to correlate with the abuse potential of drugs of 
abuse.  Effects will be tested using linear mixed effects models with peak change on each DEQ 
item as a response variable, cigarette-preference (menthol vs. non-menthol) as a between-subject 
factor, nicotine delivery condition as a within-subject factor and their interaction. Period effects 
will be controlled for by including test day as an additional predictor in the models. Random 
effects for subject and condition within subject will be used to account for correlations between 
repeated measures. Because of the potential skewed distributions of the subjective effects data, 
transformations will be applied as necessary. We will evaluate the main and interactive effects of 
menthol cigarette preference and delivery rate. We anticipate statistically significant main effects 
of menthol-preference, nicotine delivery rate and a significant interaction between menthol-
preference and nicotine delivery rate. To better understand the dose effects of nicotine delivery 
rate and whether they are moderated by menthol preference, we will construct specific contrasts 
among the four doses to test whether there is an indication of significant linear, quadratic, linear 
on log-scale or sigmoidal dose-response relationships across, or within menthol-preference 
groups. The possible dose-response curves identified by the specific mean contrasts will be 
compared by fitting linear and non-linear (as necessary) dose-response models with continuous 
dose and selecting the best-fitting model by the Akaike’s Information Criterion (AIC).  
To test for an effect of delivery rate on smoking urges, assessed by the BQSU (Factor 1 and 
2) scores, we will use similar modeling approach described for subjective effects but we will also 
include time as a within-subject factor with outcomes for minute 0, 10, 30, 60 and 120. We 
anticipate a significant main effect of menthol-preference, nicotine delivery rate and potentially a 
significant interaction between menthol-preference and nicotine delivery rate.  
Rationale for sample size:  
The study will have 80% power to detect large effect sizes (f=0.4) for the main effect of menthol 
with 31 individuals per group at 0.025 significance level (Bonferroni-adjusted for two outcome 
measures) for each hypothesis). Our previous study showed large magnitude effects of 
preference for mentholated cigarettes on feeling good and stimulated effects (d=0.8 or larger, 
corresponding to f=0.4 or larger). Our pilot data also showed large effects of nicotine (f>0.6) and 
the rate of infusion effects are expected to be similarly strong (42, 48, 54, 83). With 28 


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individuals per group we have 80% power to detect effect sizes of this magnitude (f>0.5) for the 
within-subject effect of nicotine delivery rate and in the interaction between nicotine delivery 
rate and menthol. To account for 20% drop-out rate, we will recruit 35 participants for each 
group. 
 
 
 
11. Risks and benefits: 
Potential risks 
There are potential risks, discomforts and inconveniences associated with the participation in this 
study. These may be due to nicotine administration, blood drawing, and other study procedures. 
1) The administration of nicotine may cause cardiovascular, autonomic, and gastrointestinal 
complications. Large doses of nicotine may cause nausea, vomiting, abdominal pain, 
hypersalivation, diarrhea, dizziness, confusion, hearing and vision problems, syncope, seizures, 
hypotension, irregular pulse, and death. However, these toxic effects occur at doses 10-20 times 
that which will be used in our study.  Other potential risks from this study include administering 
a drug that has addictive potential. However, since only subjects with a history of cigarette use 
are to be included, we will not be exposing subjects to the risks of nicotine for the first time. 
Additionally, we are not enrolling subjects who are seeking treatment to quit smoking. Over the 
last 5 years, we have administered nicotine intravenously to more than 100 smokers and have not 
encountered any adverse events from nicotine. 
2) Blood Drawing: Subjects will have less than 300 ml of blood drawn as a result of their 
participation in the study. Blood drawing can cause some pain and may result in bruising.  
3) Study procedures: On the test days, subjects will not be able to smoke for 10 hours. During 
this cigarette abstinence period, subjects may experience symptoms of nicotine withdrawal such as 
craving cigarettes, mild anxiety, restlessness, irritability, difficulty concentrating, loss of energy, and 
excessive hunger.     
4) Protection of Subjects: To participate in a study, each subject must give informed consent. All 
potential risks will be described in detail to the subjects in the consent form. The personnel in the 
laboratory have been certified in either Advance Cardiac Life Support (ACLS) or Basic Life 
Support. If a problem arises, the subject will be treated immediately. Confidentiality in this study 
is of the utmost importance to us. All information obtained will be stored in coded form. The 
names of the subjects will be used in hospital records.   
 
12. Safety 
Prior to initiating any research activity, each subject must give informed consent. Before the 
study, the subjects will be informed about all potential risks of the study. Our inclusion and 
exclusion criteria will be applied by experienced professionals who will be carefully trained and 
monitored to accept only appropriate subjects into the study. Thus, effective screening will 
exclude subjects who would be placed at a greater risk. Eligibility is determined by the medical 


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and psychiatric history, drug use history, the physical examination, and the laboratory studies 
done prior to beginning this research protocol. 
For nicotine administration sessions, a physician or a nurse will be present and subjects will be 
attached to a cardiac monitor as well as a blood pressure and heart rate monitoring device. An IV 
catheter will be in place throughout the session. Subjects will be administered nicotine only if the 
systolic blood pressure is <150 mmHg and heart rate is < 90 beats/minute. Subjects will be 
terminated from the study if the blood pressure at any time is >170/110 mm Hg, the heart rate is 
> 130 beats/min, or if they develop signs and symptoms compatible with nicotine toxicity. 
Subjects will remain in the laboratory for at least an hour after the last nicotine administration. 
These procedures have been developed as part of our IND for IV nicotine.  
Confidentiality will be protected by having records identified by code number only with the 
master list including names kept in a sealed envelope in a locked file in the Principal 
Investigator's office and by the pharmacy. Subjects will be given telephone numbers to call in 
case of emergency, 24 hours a day.    
12.1 Potential benefits of the proposed research to the subjects and others.  There will be no 
direct benefit to subjects participating in this study. However, subjects will receive complete 
medical and psychological evaluation. Cigarette smokers will be given anti-smoking literature 
and treatment resources will be provided for smoking cessation.  
12.2 Importance of the knowledge to be gained. This proposed study may help to develop new 
and more effective tobacco control policies. We believe that the risk/benefit ratio for this study is 
acceptable, and that the benefits of the proposed studies outweigh the potential risks to subjects.  
12.3 Data safety and monitoring plan: The Principal Investigator will conduct a review of all 
adverse events and determine the attribution and grade of severity of the adverse event by using 
the following scales: 
Attribution of Risk Categories: 
Definite:  Adverse event(s) will clearly be related to investigational agent(s) or other 
intervention 
Probable: Adverse event(s) will likely be related to investigational agent(s) 
Possible:   Adverse event(s) may be related to investigational agent(s) 
Unlikely:  Adverse event(s) will doubtfully be related to investigational agent(s) 
Unrelated: Adverse event(s) will clearly not be related to the investigational agents(s) 
Grades of Risk: 
0: No adverse event or within normal limits 
1:  Mild adverse event 
2:  Moderate adverse event 
3:  Severe adverse event resulting in hospitalization or prolongation of existing 
hospitalization, a persistent or significant disability/incapacity, or a congenital 
anomaly/birth defect  
4:  Life-threatening or disabling adverse event 


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5:  Fatal adverse event 
Serious adverse events (SAEs) include any untoward medical occurrence that at any dose results 
in death or the immediate risk of death, hospitalization or the prolonging of an existing 
hospitalization, persistent or significant disability/incapacity or a congenital anomaly/birth 
defect. Subjects will be terminated from participation if the investigator feels that subjects' health 
or well-being may be threatened by continuation in the study. Serious unanticipated and 
anticipated adverse events will be reported within 48 hours to the VA Hospital and Yale IRB, 
and NIDA. We will directly report to the FDA, whenever their magnitude or frequency exceeds 
expectations.   
The risk associated with participating in this study is moderate, because nicotine administered 
may be associated with mild side effects. Serious side effects associated with this treatment are 
not expected. This project will be monitored by a Data and Safety Monitoring Board (DSMB) 
because the study involves double-blind treatment of smokers with nicotine. This board is 
composed of persons not otherwise affiliated with the clinical study who are experienced in 
various aspects of the conduct of clinical trials for the treatment of addictive disorders. We 
propose three investigators located here in Connecticut who are not directly involved in this 
study – Declan Berry, Ph.D., Alec Buchanan, M.D., and Brian Kiluk, M.D. as the members of 
the DSMB. The members of the DSMB and all study Investigators will complete Conflict of 
Interest forms created by Yale’s IRB in accordance with NIH guidelines.   
In order for the DSMB to fulfill its mission of assuring the safety of human subjects and the 
scientific integrity of the studies conducted, the Board will have access to accumulating study 
outcome data in a manner that will protect its confidentiality and preserve its statistical integrity. 
The Board will examine accumulating data to assure that the risks and benefits of participation 
remain acceptable and that the results of the study will be considered scientifically reliable. The 
conditions under which the Board will examine this data are described below. This monitoring 
will be consistent with NIH policy regarding the protection of human subjects in research, and 
FDA guidance on statistical practices for clinical trials (ICH E9) and good clinical practices 
(ICH E6). In general, the data to be reviewed will include screening data, baseline data, efficacy 
data, and safety data.   
The study will be monitored for safety in an ongoing way as well as three times each year 
formally by the DSMB.  The P.I. will attend an initial part of this meeting to present the study’s 
adverse events and ongoing subject accrual, as well as any potential study design changes under 
consideration.  The remainder of the meeting will not include any direct study personnel until the 
end of the meeting, when the DSMB will convey directly to the P.I. any safety or study conduct 
concerns, as well as requests for potential interim analyses.    
Following each DSMB meeting written minutes will be prepared and distributed summarizing 
any recommendations. These written reports will insure timely communication with the study 
P.I. with preparation of any protocol amendments necessary. After each DSMB meeting, this 
written report will describe all recommendations including additional safety steps. The FDA 
adverse drug experience reporting timelines will be utilized as timelines to disseminate feedback 
from the DSMB to the principal investigator and sub investigators. That is, three days for acute 
circumstances and ten days for non-acute circumstances.  
 


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13. Informed consent: Subjects will be recruited from the New Haven area by newspaper 
advertisements and fliers. Interested subjects will be informed about the study over the telephone 
and asked for current use of drugs and medical problems. If subjects are interested, they will then 
come into the clinic for a full screening evaluation. Upon arrival, a research assistant will review 
the detailed consent form and will ask questions to make sure that the subjects understand the 
procedure and their rights and informed consent will be obtained.   
14. Information Security/Confidentiality: Confidentiality in this study is of the utmost 
importance to us. All information obtained will be stored in coded form.  
Personally identifiable information (PII) and protected health information (PHI) that is obtained 
from subjects or about them will be protected by the research team who will follow all guidance 
provided in the following VHA HANDBOOKS and DIRECTIVE: 
 
• VHA HANDBOOK 1605.1, PRIVACY AND RELEASE OF INFORMATION Dated 
May 17, 2006 
 
• VHA HANDBOOK 1907.01, HEALTH INFORMATION MANAGEMENT AND 
HEALTH RECORDS Dated August 25, 2006 
 
• VHA HANDBOOK 6500, INFORMATION SECURITY PROGRAM Dated September 
18, 2007 
 
• MEMORANDUM FOR UNDER SECRETARIES, ASSISTANT SECRECTARIES 
AND OTHER KEY OFFICIALS, SUBJECT: Protecting Information Security and 
Privacy Dated February 27, 2009 
 
• VHA HANDBOOK 1200.12, USE OF DATA AND DATA REPOSITORIES IN VHA 
RESEARCH Dated March 9, 2009 
 
All data collected will be the property of the Department of Veterans Affairs whether in paper or 
electronic form and will be secured utilizing the following methods: 
 
Paper:  
• All paper documents will be stored on VA property unless authorized by the Director, 
Information Security Officer, and Privacy Officer in writing.  
• All paper documents will be locked in an approved file cabinet with only members of the 
research team having access.  
 
Electronic: 
• All information in electronic form will be stored on VA servers behind the VA firewall. 
• All portable media will meet or exceed FIPS 140-2 compliance and encryption. And will 
be approved in writing by the Information Security Officer.  
 
The location(s) where information will be stored is (are) Building 35, rooms 19 and 39 
The people or agencies that will have access to the information are the study investigators. 
 


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No information related to this research will be released to any third party or disclosed outside of 
the VHA – except as required or permitted by law. 
 
 
Research records will have identifiers removed and will be stored with a code number linked to 
subjects.  The code will not be derived from any personal identifiers.  The key to the code will be 
kept in a locked file cabinet, located in Bldg 35, room 19. Subjects’ identity will not be revealed 
in any reports or publications resulting from this study. 
15. Location of Study: This study will be conducted in Ward G9W (the Biostudies Unit) located 
in Building 1 at the West Haven VA Medical Center. 
16. Payment: Subjects will be paid cash; $30 for participating in the screening and $150 for 
each of the 5 lab sessions. In addition, to help offset transportation costs, subjects will be paid 
$20 for each of the 5 lab sessions. If the subject is asked to return in addition to these 5 visits for 
any reason, they will be paid $20 for travel. If the subjects choose to terminate a session 
prematurely, or a session is terminated early for medical reasons, they will receive full payment 
for that day.  If they become ineligible to continue in the study due to non-compliance with study 
procedures, they will only be paid for the portions of the study in which they have participated. 
Subjects may be paid up to $880.00 if all parts of the study are completed. Payment may exceed 
$880.00 if the subject is asked to return in addition to the screening visit and the 5 lab sessions 
for any reason. The payment will increase by $20 for each additional visit. 
Visits 
Amount paid 
Total  
Screening Visit 
$30.00 
30.00 
Lab session  
$150 each lab session  
Five lab sessions $750 
Travel to each lab session  
20.00 each lab session  
Travel for 5 session  $100 
 
Max total  
$880.00   
If subject is asked to return 
for additional testing or visit  
$20 for travel  
$20.00 
 
 
17. Funding Source: An R03 DA043004-01 grant from NIDA (pending). 
18. Duration: The entire study will take approximately 2 years to complete.    
19. References: 
 
 
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