Multimodal Neuroimaging Genetic Biomarkers of Nicotine AddictionSeverity

• INCLUSION CRITERIA:

All participants must:

1. Be between the ages of 18-60. Assessment tool(s): Edinburgh Handedness Inventory.Although left-handed individuals will not be excluded, we will track handedness.Justification: Some of the neural processes assessed in this protocol may belateralized in the brain. In order to assess potential variance, participantshandedness will be documented.

2. Be in good health. Justification: Many illnesses may alter fMRI signals as well ascognitive processes and neural functioning. Assessment tool(s): Participants willprovide a brief health history during phone screening, and undergo a medical historyand physical examination with a qualified IRP clinician.

3. Be free of active DSM-IV dependence, on alcohol or any drug except nicotine. Pastactive dependence is acceptable provided it is at least two years in the past. Thosewith past dependence on substances other than alcohol or marijuana may not have anycurrent use (past 6 months) of the substance on which they were dependent.Individuals with past dependence on either alcohol or marijuana who report currentuse of the previously dependent substance may be included, provided they do notcurrently meet any criteria for dependence, with the exception of tolerance. MAI mayexclude on a case-by-case basis for heavy alcohol or drug use not meeting dependencecriteria but likely to interfere with data quality. Justification: Dependence onother substances (drugs or alcohol) may result in unique CNS deficits that couldconfound results and introduce excessive variance. Assessment tool(s): The SCIDand/or the Mini International Neuropsychiatric Interview (M.I.N.I) and clinicalsubstance abuse/dependence assessment. While recreational/intermittent use ofalcohol and/or marijuana will be tolerated in all participant groups, individualswill be excluded if they meet current or recent (within 2 years) DSM-IV diagnosticcriteria for dependence on any substances. A positive drug test for marijuana willnot be exclusionary as long as participants have not used in the 24hrs preceding theimaging visits. In the event of a positive drug test for marijuana, self-reports ofcurrent marijuana use will be used to differentiate intermittent/infrequent fromchronic/frequent users.

4. Be able to abstain from alcohol 24hrs before each of the imaging sessions and ableto abstain from caffeine 24hrs before each session. Justification: Alcohol andcaffeine modulate neural functioning in a way that would complicate datainterpretation. Assessment tool(s): Self-report and breathalyzer.

5. For the treatment and non-treatment seeking groups, must have a urine cotinine levelcorresponding to smoker/nicotine user status for the specific test being used (typically corresponding to a urine cotinine above about 200 ng/ml) and have beensmoking or vaping consistently for at least the past year (excluding quit attempts).Based on the correlation between self-reported cpd/FTND and urine cotinine levels [85a, 85b], a single inclusion criterion will be easier to manage and provideadequate characterization of nicotine dependent participants. Urine cotinine levelprovides a biomarker that does not rely on self-report/memory. Quit attempts will beassessed via clinical interview and judgment. Justification: The present protocol isinterested in neurobiological mechanisms that underlie nicotine dependence-inducedplasticity and is thus contingent on the presence of nicotine dependence. Assessmenttool(s): Self-report, commercial urine cotinine test corresponding tosmoker/nicotine user status for the specific test being used, typicallycorresponding to a urine cotinine above about 200 ng/ml.

6. For the treatment and non-treatment seeking groups, must be willing to attempt anacute abstinence period lasting approximately 48 hours.

7. For the treatment seeking group, be actively seeking treatment for nicotinecessation and willing to engage in 12-weeks of treatment involving weekly counselingsessions, as well as follow-up imaging and behavioral assessments followingtreatment onset.

8. For the ex-smoker group, must have smoked approximately 8 or more cigarettes per dayfor at least 1 year, and have remained abstinent continuously for at least the last 12 months. Justification: While serum cotinine level has been shown to be a moreaccurate measure of cigarette smoking than CPD [85c], it is impossible in thecurrent design to collect retroactive serum cotinine levels from exsmokers. Instead,CPD must be equated with the urine cotinine levels of current treatment andnontreatment seeking groups. The low-end cotinine level for the inclusion ofsmokers/vapers in this protocol is about 200 ng/mL. In adult smokers, a nicotineintake of approximately 1 mg can be estimated from a blood cotinine level of 12.5ng/mL) [85d]. Thus, to have achieved a blood cotinine level of 200ng/mL, ex-smokerswould have to self-report consumption of 16 mg of nicotine per day which equates toapproximately 8 CPD (0.36-2.62 mg nicotine yield per cigarette [85e]. Given thesecalculations, the inclusion criterion for the ex-smoker group has been lowered to 8CPD. Assessment tool(s): Self-report, commercial urine cotinine test correspondingto non-smoker status for the specific test being used, typically corresponding to aurine cotinine under about 20 ng/ml, CO < 6.

9. For the non-smoking/vaping control group, less than 20 times of lifetime use ofnicotine containing products and vaping of non-nicotine containing products, none inpast year and no history of daily nicotine use. Justification: Minimal nicotineexposure in the control group is required to assess differences between controls andthe nicotine groups. Assessment tool(s): Self-report, commercial urine cotinine testcorresponding to non-smoker status for the specific test being used, typicallycorresponding to a urine cotinine under about 20 ng/ml, CO < 6.

EXCLUSION CRITERIA:

3.3 Exclusion criteria:

Participants will be excluded if they:

1. are not suitable to undergo an fMRI experiment due to certain implanted devices (cardiac pacemaker or neurostimulator, some artificial joints, metal pins, surgicalclips or other implanted metal parts), body morphology, or claustrophobia.Justification: MR scanning is one of the primary measurement tools used in theprotocol. Assessment tool(s): Prospective participants will fill out an MRIscreening questionnaire and undergo an interview with an MR technologist. Questionsconcerning suitability for scanning will be referred to the MR Medical SafetyOfficer. Prospective participants will be questioned about symptoms ofclaustrophobia and placed in the mock scanner during their first visit to assess forpossible difficulty tolerating the confinement of the scanner and for ability to fitinto the scanner.

2. have coagulopathies, history of, current superficial, or deep vein thrombosis,musculoskeletal abnormalities restricting an individual s ability to lie flat for extended periodsof time. Justification: MR scanning sessions require participants to lie flat ontheir backs and remain perfectly still for approximately two hours. Therefore,conditions that would make that difficult (e.g. chronic back pain, significantscoliosis) or dangerous (e.g. familial hypercoagulability syndrome, history ofthrombosis) will be exclusionary. Assessment tool(s): History and physicalexamination by a qualified IRP clinician, supplemented with a trial of lying in themock scanner to assess comfort issues.

3. have HIV or Syphilis. Justification: HIV and Syphilis both can have central nervoussystem (CNS) sequelae, thus introducing unnecessary variability into the data.Assessment tool(s): Oral HIV blood test if oral test is + and STS+ without adequateprior treatment

4. regularly use any prescription (e.g., benzodiazepines, antipsychotics,anticonvulsants, barbiturates), over-the-counter (e.g., cold medicine) or herbalmedication (e.g., Kava, Gingko biloba, St. John s wort) that may alter CNS function,cardiovascular function, or neuronal-vascular coupling. Antidepressant use will beallowed if an individual is on a stable dose of an SSRI or SNRI for ~6 weeks. Asneeded, benzodiazepine use is also allowed, but the individual must test negativefor benzodiazepines on the drug screen. Justification: The use of some medicationsmay alter the fMRI signal and/or neural functions of interest in the current study.Consistent antidepressant use or infrequent use of benzodiazepines is unlikely todrive study-related changes in brain function. Allowing such medication use willalso make it possible to study nicotine dependent individuals who continue to smokedespite receiving treatment for a mood disorder. Assessment tool(s): History andcomprehensive urine drug screening to detect antidepressants, benzodiazepines,antipsychotics, anticonvulsants, and barbiturates.

5. have any current neurological illnesses including, but not limited to, seizuredisorders, frequent migraines or on prophylaxis, multiple sclerosis, movementdisorders, history of significant head trauma, or CNS tumor. Justification:Neurological diseases alter CNS function and, possibly, the neuronalvascularcoupling that forms the basis of the fMRI signal. Assessment tool(s): History andphysical examination by a qualified IRP clinician, urine drug screening foranticonvulsants not disclosed by history. History of head trauma with loss ofconsciousness of more than 30 minutes or with postconcussive sequelae lasting morethan two days, regardless of loss of consciousness, will be exclusionary. The MAIwho will also retain discretion to exclude based on a history of neurologicalillness that may compromise data integrity.

6. Have current major psychiatric disorders to include, but not limited to psychoticdisorders, or substance-induced psychiatric disorders, or risk of suicide orcurrently on antipsychotic medication treatment. Individuals with current majordepressive disorder (MDD) and related anxiety will be allowed if currently stable,as assessed by the MAI. The MAI will reserve the right to exclude on the basis ofpsychiatric history not explicitly described in this criterion. Justification:Psychiatric disorders involve the central neural system (CNS) and, therefore, can beexpected to alter the fMRI measures being used in this study. However, mooddisorders such as MDD are highly comorbid with nicotine dependence. Including thispopulation will generate results that are more representative of nicotine dependentindividuals. Assessment tool(s): Computerized SCID or M.I.N.I., Beck DepressionInventory, Beck Anxiety Inventory, Adult ADHD Self-Report Scales and clinicalinterview confirmation by clinician.

7. Are cognitively impaired or learning disabled. Justification: Cognitive impairmentand learning disabilities may be associated with altered brain functioning inregions recruited during laboratory task performance. Cognitive impairment mayaffect one s ability to give informed consent. Assessment tool(s): Historyexamination and validated IQ test, such as the Wechsler Abbreviated Scale ofIntelligence (WASI) or Shipley-2. IQ estimate must be 80 or over.

8. have significant cardiovascular, cerebrovascular, or respiratory conditions.Justification: Such conditions may alter blood flow, the fMRI signal and otherautonomic signals, and increase risks associated with nicotine patch and/ore-cigarette use. Assessment tool(s): History and physical exam, including 12-leadEKG.

9. have any other major medical condition that in the view of the investigators wouldcompromise the safety of an individual during participation. Justification: Manyillnesses not explicitly covered here may increase risk or alter important outcomemeasures. Assessment tool(s): History and physical examination by a qualified IRPclinician and CBC, urinalysis, NIDA chemistry panel (liver function tests,electrolytes, kidney function). The following lab values will result in exclusionfrom the study: i. Hemoglobin < 10 g/dl ii. White Blood Cell Count < 2400/ l iii. Liver Function Tests > 3X normal iv. Serum glucose > 200 mg/dl v. Urine protein > 2+ vi. Serum creatinine > 2 mg/dl vii. Estimated creatinine clearance <60ml/min The MAI will retain discretion to exclude based on less extreme lab results. Afterthe screening process has been completed, the MAI will take into account all datacollected in order to decide if there is an existing medical illness that wouldcompromise participation in this research.

10. are pregnant, planning to become pregnant, or breastfeeding. Females are instructedin the consent to use effective forms of birth control during the study period.Justification: study procedures and drugs used in the current protocol maycomplicate pregnancy or be transferred to nursing children. Assessment tool(s):Urine and/or serum pregnancy tests, and clinical interview. Urine pregnancy testswill also be conducted at the beginning of each imaging visit.

11. Are non-English speaking. Justification: To include non-English speakers, we wouldhave to translate the consent and other study documents and hire and train bilingualstaff, which would require resources that we do not have and could not justify,given the small sample size for each experiment. Additionally, the data integrity ofsome of the cognitive tasks and standardized questionnaires used in this study wouldbe compromised as they have only been validated in English. Most importantly,ongoing communication regarding safety procedures is necessary when participants areundergoing MRI procedures. The inability to effectively communicate MRI safetyprocedures in a language other than English could compromise the safety ofnon-English speaking participants. Assessment tool(s): self-report....