Download 6. RESEARCH PLAN A. Statement of Hypothesis and Specific Aims

Principal Investigator/Program Director (Last, first, middle):
Kotlyar, Michael
6. RESEARCH PLAN
A. Statement of Hypothesis and Specific Aims
Cigarette smoking is a well-established cause of cardiovascular disease. Although smoking cessation is the
best method by which to decrease smoking-induced cardiovascular disease, unfortunately at any given time
only 20% of smokers report that they are motivated to stop smoking, with only 40% having made quit
attempts in the past year (CDC, 2001; Etter et al., 1997). Additional research is necessary to determine the
mechanisms by which smoking contributes to cardiovascular disease and methods need to be investigated by
which smoking induced cardiovascular disease can be reduced in those unwilling to quit smoking. The
predominant mechanisms responsible for smoking induced cardiovascular injury is unclear, however one
hypothesis holds that repeated sympathetic nervous system surges occurring when a cigarette is smoked
during stressful periods may contribute to the deleterious effect of smoking on cardiovascular health (Epstein
and Perkins, 1988).
Upon smoking a cigarette a number of physiological responses, such as increases in blood pressure and heart
rate, have consistently been observed (Benowitz et al., 1988; Gourlay and Benowitz, 1997; Zevin et al.,
2001). This physiological response to mental stress is similar to that observed in response to smoking (e.g.
increases in blood pressure, heart rate, catecholamine concentrations) (Schoder et al., 2000; Yoshida et al.,
1999). When smoking is combined with exposure to stress, the increases in blood pressure and heart rate are
additive (Perkins et al., 1986; Pomerleau and Pomerleau, 1987). Exaggerated cardiovascular response to
stress has been associated with the development and progression of coronary artery disease (Jiang et al.,
1996), therefore combining stress with smoking likely results in greater cardiovascular harm than either
smoking or stress individually. Since smokers often smoke in response to stressful situations, interventions
that decrease the physiological response to mental stress during cigarette smoking may reduce the negative
cardiovascular effects in smokers.
Recent studies suggest that the selective serotonin reuptake inhibitor (SSRI) class of antidepressants have
beneficial effects in people at increased risk for cardiovascular events (e.g. smokers, patients post myocardial
infarction). One trial found that SSRI use in smokers was associated with a significant decrease in the risk of
myocardial infarction (Sauer et al., 2001). Other studies reported that SSRI’s decreased the risk of
cardiovascular events when used in post myocardial infarction patients who have symptoms of depression or
low perceived social support (Berkman et al., 2003; Glassman et al., 2002). The mechanism by which
SSRI’s may have conferred these protective effects is unknown, however one hypothesis is that SSRI’s
decrease the physiological response to stressful situations. Several lines of evidence suggest that SSRI’s
attenuate the physiological response to stress regardless of whether symptoms of depression are present,
however there is currently no data regarding the effect of SSRI’s on stress reactivity in smokers or during the
acute smoking period. This represents an important gap in knowledge since decreasing physiological
response to stress may be an effective mechanism by which to lower cardiovascular risk in smokers.
Our long-term objective is to identify pharmacological interventions that can increase smoking quit rates or
decrease the cardiovascular harm associated with smoking. The immediate objective of this application,
which is the first step in pursuit of our long-term goal, is to assess the effects of paroxetine (an SSRI) on the
cardiovascular response to mental stress tasks in smokers. The central hypothesis of the application is that
the serotonergic antidepressant paroxetine will affect cardiovascular reactivity to mental stress.
We plan to test our hypothesis and accomplish the objective of this application by pursuing the following
specific aims:
1. Assess the effects of paroxetine on physiological response (blood pressure, heart rate and
plasma catecholamine concentrations) during laboratory administered mental stress tasks
administered immediately after smoking.
We hypothesize that relative to placebo, paroxetine will reduce physiological response to mental stress.
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2. Assess the effects of paroxetine on psychological discomfort during laboratory administered
mental stress tasks administered immediately after smoking.
We hypothesize that relative to placebo, paroxetine will reduce perceived psychological discomfort to mental
stress tasks.
The proposed work is innovative, since this mechanism of action of antidepressant pharmacotherapy has not
been previously studied in smokers and may provide a mechanism by which SSRI’s reduce cardiovascular
morbidity in smokers. It is our expectation that there are important differences between antidepressants with
regards to their effect on cardiovascular stress response. This is significant because data generated from this
and follow up studies will provide insights into the mechanisms of smoking induced cardiovascular disease
and identify the preferred antidepressant in the treatment of smokers, particularly depressed smokers or
others at increased risk of cardiovascular events. Furthermore, the efficacy of using antidepressants in those
patients who are non-depressed but are highly reactive to mental stressors may be investigated as well. An
additional line of future investigations based on the data generated would focus on the effect of decreasing
physiological stress response on smoking behavior in smokers who are highly reactive to stressful events.
B. Background, Significance and Rationale
Cigarette smoking is a well-established contributor to cardiovascular morbidity and mortality. It has been
estimated that every year over 148,000 deaths in the United States due to cardiovascular disease are
attributable to smoking (CDC, 2002). The potential mechanisms by which smoking contributes to
cardiovascular disease are numerous and include, among others, acceleration of the development of
atherosclerosis, predisposition to thrombus formation and predisposition to myocardial ischemia (Taylor et
al., 1998; Villablanca et al., 2000). Magnitude of the physiological reaction to stressful situations is a
known risk factor for cardiovascular morbidity and mortality that is of particular relevance to smoking.
Many of the physiological reactions to a stressful situation (e.g. increased heart rate, increased blood
pressure, release of catecholamines) are similar to reactions observed during and shortly after smoking a
cigarette. Since stress is often a precipitant of smoking (Cohen and Lichtenstein, 1990; Swan et al., 1988)
and the cardiovascular effects of smoking and stress appear to be additive (MacDougall et al., 1983; Perkins
et al., 1986; Pomerleau and Pomerleau, 1987), ways to reduce the reactivity to mental stress may have
significant cardiovascular benefits in smokers. Although, smoking cessation is clearly the best method by
which to reduce smoking related cardiovascular disease, unfortunately at any given time only 20% of
smokers report that they are motivated to stop smoking (Etter et al., 1997). Even among those who attempt
to quit smoking, one-year success rates rarely exceed 30%. The remaining smokers are either unwilling to
stop smoking or are not motivated to quit smoking because they do not perceive themselves as able to
successfully quit, often due to numerous previous failed cessation attempts. Identifying and attenuating
mechanisms by which smoking causes cardiovascular disease is important in improving health in recalcitrant
smokers.
i. Stress Reactivity and Cardiovascular Disease.
When individuals are subjected to mental stress tasks in a laboratory setting, increases in efferent
sympathetic tone occur. This can be measured by increases in blood pressure, heart rate, cardiac
contractility, and plasma catecholamine concentrations (Schoder et al., 2000; Yoshida et al., 1999). Such
“mental stress” tasks involve, for example, asking subjects to speak in public or solve timed math problems
while being observed. An individual’s physiological responses to mental stress in such laboratory settings
may correlate with the responses experienced by that individual during stressful situations that commonly
occur in everyday life.
As can be expected, there is much variability between individuals in sympathetic increase during mental
stress tasks; however, a given individual’s response to stress is relatively stable over time (Fauvel et al.,
1996; Jern et al., 1995). Those who exhibit a higher than average increase in blood pressure, heart rate, or
plasma catecholamines (“high reactors”) are known to be at higher risk for developing coronary artery
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disease (Barnett et al., 1997; Matthews et al., 1998). Those high reactors who ultimately develop coronary
artery disease have higher mortality rates than similarly afflicted patients with coronary artery disease who
do not react as strongly to mental stress (“low reactors”) (Jiang et al., 1996).
Several studies suggest that increased reactivity to mental stressors results in an accelerated rate of coronary
atherosclerosis. Early literature established a correlation between Type A personality and coronary artery
disease (Spence, 1997). Subsequent animal data indicated that monkeys that exhibited high heart rate
reactivity to a stressful event (threat of capture) had coronary artery stenosis that was nearly twice as severe
as those with low heart rate reactivity (Manuck et al., 1988). Several studies in humans have also
demonstrated that increased reactivity to mental stress (as assessed by exaggerated increases in systolic
blood pressure) is correlated with greater atherosclerotic plaques 2 years after mental stress testing was
performed (Barnett et al., 1997; Matthews et al., 1998). Additionally, increases in systolic blood pressure
during mental stress have been correlated with increased weight and height adjusted left ventricular mass
(LVMI), a known risk factor for cardiac morbidity and morality when measured in healthy individual (Kop
et al., 2000).
In addition to potentiating the development of CAD, high reactors are at increased risk for cardiovascular
events once CAD is established. In contrast to patients without cardiovascular disease in whom mental stress
testing results in an increase in myocardial blood flow, 40% to 70% of patients with existent CAD develop
functional decreases in blood flow (ischemia) during mental stress (Rozanski et al., 1988; Stone et al., 1999).
When 24 hour ambulatory ECG measures are performed on patients who experience ischemia during a
laboratory mental stress challenge, these patients are found to have a greater number of ischemic episodes
and longer periods of ischemia during their daily lives (Blumenthal et al., 1995; Stone et al., 1999). In the
non-laboratory setting, ambulatory ECG monitoring demonstrates that the relative risk of myocardial
ischemia in the hour following high levels of negative emotions was substantially higher than that for other
time periods (Gullette et al., 1997; Selwyn et al., 1985). Ultimately high reactors with cardiovascular
disease (i.e. CAD or stable angina) have a mortality rate several times higher than their less reactive peers
(Jain et al., 1995; Jiang et al., 1996; Krantz et al., 1999; Manuck et al., 1992). One study in which patients
with stable CAD underwent both mental stress and exercise stress testing found that myocardial ischemia
(assessed by radionuclide ventriculography) during mental stress was more predictive of future cardiac
events than when observed during exercise stress (Jiang et al., 1996).
ii. Stress, Stress Reactivity and Smoking.
The relationship between smoking and stress has been assessed in both laboratory and naturalistic studies.
Several laboratory studies have demonstrated that during various stressful situations (e.g. public speaking,
unpleasant noise), smoking intensity or amount smoked increases as does self-reported desire to smoke
(Cherek, 1985; Perkins and Grobe, 1992; Pomerleau and Pomerleau, 1987; Rose et al., 1983). Based on
retrospective analyses in smokers who were attempting to quit smoking, many smokers report that a lapse
occurred while experiencing some form of stress or tension (Borland, 1990; Brandon et al., 1990; Cummings
et al., 1985; Shiffman, 1982; Swan et al., 1988). Studies have suggested that those maintaining high levels
of stress may be more likely to progress from experimental to regular smoking and less likely to successfully
quit smoking (Cohen and Lichtenstein, 1990; Orlando et al., 2001; Siqueira et al., 2000). Investigations
assessing whether smokers with exaggerated responses to stressors are more likely to relapse after a
cessation attempt have reported that those who can sustain longer-term abstinence have lower heart rate
responses to smoking cues (Abrams et al., 1988) and to social stressors (Abrams et al., 1987; Niaura et al.,
1989; Niaura et al., 2002a). Additionally, successful abstainers have lower heart rate and blood pressure
reactivity to a mental arithmetic or public speaking task (Emmons et al., 1989; Swan et al., 1993) and are
less likely to prematurely terminate an arithmetic task (Brown et al., 2002).
The effects of acute smoking on cardiovascular parameters such as heart rate and blood pressure have been
examined in numerous studies. Laboratory studies in which smokers are asked to smoke one to two
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cigarettes (usually after abstaining overnight), typically find that heart rate increases by approximately 20
beats per minute with blood pressure (systolic and diastolic) increasing by approximately 15 mmHg (Arcavi
et al., 1994; Benowitz et al., 1988; Dembroski et al., 1985; Gourlay and Benowitz, 1997). Maximal
increases in heart rate and blood pressure occur within the first 15 to 20 minutes of smoking (Arcavi et al.,
1994; Benowitz et al., 1988; Gourlay and Benowitz, 1997). Approximately 2 hours after smoking these
cardiovascular measures return to levels close to those observed prior to smoking (Arcavi et al., 1994). The
effect of smoking on plasma catecholamine concentrations is less clear. Although some studies have not
found an increase after smoking (Gourlay and Benowitz, 1997), many other studies have found increased
catecholamine release in smokers and increased concentrations after smoking (Cryer et al., 1976; Grassi et
al., 1994; Zevin et al., 2001). Studies finding that adrenergic antagonists attenuate smoking induced blood
pressure and heart rate increases suggest that the cardiovascular effects of smoking are secondary to
sympathetic nervous system activation (Cryer et al., 1976; Groppelli et al., 1990).
Due to the substantial literature suggesting that stress may lead to smoking and that individually both mental
stress and smoking lead to sympathetic nervous system activation, a number of studies have been conducted
assessing the effect of combining mental stress and smoking on cardiovascular response. Most studies have
found that stress and smoking are additive in their impact on blood pressure and heart rate reactivity (Davis
and Matthews, 1990; Dembroski et al., 1985; MacDougall et al., 1983; Perkins et al., 1986; Pomerleau and
Pomerleau, 1987; Poulton, 1977; Ray et al., 1986). These additive effects occur within a relatively short
time frame after smoking – an hour after smoking, reactivity is substantially less marked than seen earlier
(Perkins et al., 1992). Since smokers often increase their smoking during stressful situation, it has been
suggested that the exaggerated sympathetic response that occurs in smokers during stressful stimuli may
contribute to the well-established cardiovascular risks that smoking imparts (Epstein and Perkins, 1988).
At present, despite the known dangers of an exaggerated sympathetic response to mental stress tasks, it is not
known whether agents that can be expected to decrease the subjective discomfort during stressful periods
would also attenuate the physiological response. Beta-blockers, which block the effects of increased
norepinephrine and epinephrine secretion, have been clearly shown to reduce mortality in patients with
cardiovascular disease, particularly in the post myocardial infarction population (Hennekens et al., 1996). In
fact, atenolol, although having small effects on plasma catecholamine concentrations during mental stress,
has been found to be effective in preventing mental stress induced wall-motion abnormalities in patients with
stable angina (Andrews et al., 1998). It is unknown whether using psychiatric pharmacotherapy that can be
expected to reduce the psychological discomfort during mental stressors would also reduce the release of
catecholamines. If so, the effects of such pharmacotherapy on cardiovascular response to stress would be via
a mechanism different from that of the beta-blockers and may therefore confer additional benefit.
iii. Effects of SSRI’s on Stress Reactivity and Smoking.
Use of the selective serotonin reuptake inhibitor (SSRI) class of antidepressants in smokers has been shown
in one study to be associated with a significantly reduced incidence of myocardial infarction (MI) (Sauer et
al., 2001). This case-control study examined 653 cases (patients hospitalized with a first MI) and 2990
control subjects and used multivariate logistic regression to control for other factors commonly associated
with cardiovascular disease (e.g. age, sex, exercise, family history). It was found that the odds ratio for MI
among current SSRI users compared with non-users was 0.35 (95% CI 0.18 – 0.68). A subsequent casecontrol study (Sauer et al., 2003) examining 1080 cases (patients hospitalized with a first MI) and 4256
control subjects found similar results. Using multivariate logistic regression, this study found that the odds
ratio for MI among users of high serotonin transporter affinity SSRI’s (i.e. paroxetine, fluoxetine and
sertraline) was 0.59 (95% CI 0.39 – 0.91). Non-SSRI antidepressants were not associated with this
protective effect. Although the presence of depression was not assessed in these two studies, SSRI’s are
most commonly used to treat depression. Therefore it is likely that among those receiving SSRI’s, a greater
percentage of subjects were depressed than in the untreated group. Since the presence of depression has
been associated with an increased risk of myocardial infarction (Barefoot et al., 1996; Ford et al., 1998;
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Frasure-Smith et al., 1993; Frasure-Smith et al., 1995; Lesperance et al., 2000), one would expect that if
treating depression were to entirely reverse this risk factor, the relative risk of MI in the group taking SSRI’s
would be close to that of the untreated group. The magnitude of risk reduction suggests that SSRI’s were
conferring a protective effect independent of any antidepressant effects that they have.
A study enrolling patients within 28 days of a myocardial infarction similarly found significantly better
cardiovascular prognosis in those taking SSRI’s. This trial enrolled post-MI subjects who had either
significant symptoms of depression or low-perceived social support and randomized them to either cognitive
behavioral therapy (CBT) or usual care. Although CBT was not found to effect cardiovascular outcomes, a
post-hoc analysis comparing those who had taken SSRI’s with those who had not found that in those taking
SSRI’s the adjusted odds ratio of significant events (death or non-fatal MI) was 0.57 (95% CI 0.38-0.85)
relative to those who were not taking SSRI’s (Berkman et al., 2003). Another smaller study enrolling a
similar population also found trends suggestive of the protective effects of SSRI’s. This study enrolled
patients hospitalized for either a myocardial infarction or unstable angina who met criteria for major
depressive disorder and randomized them to receive either sertraline or placebo. Although this study was not
powered to detect differences in cardiovascular outcomes, a trend was seen for lower risk of death or urgent
cardiovascular rehospitalization among those taking sertraline (OR: 0.77; 95% CI:0.51-1.16) (Glassman et
al., 2002)
A study of working union health plan members also demonstrated that unlike tricyclic antidepressants which
were associated with increased risk of myocardial infarction, SSRI use was not (Cohen et al., 2000). There
was a trend toward decreased risk of MI in those taking SSRIs (odds ratio 0.8), however this trend did not
reach statistical significance. Several mechanisms have been suggested that would account for the seemingly
protective effect of SSRI in patients at risk for cardiovascular disease. One such hypothesis is that SSRI’s
decrease the cardiovascular response to stressful situations.
Several lines of evidence suggest that the selective serotonin reuptake inhibitors (SSRI’s) may have
sympatholytic qualities, particularly during times of stress. In humans, SSRI’s are known to be effective in
reducing both subject perceived and objective measures of autonomic arousal when used in the treatment of
psychiatric diseases characterized by increased autonomic activity (i.e. panic disorder, social phobia, posttraumatic stress disorder) (Masand and Gupta, 1999). This is particularly true during periods of mental stress
(DeVane et al., 1999; Tucker et al., 2000), as demonstrated by attenuated heart rate and blood pressure
responses after fluvoxamine therapy in patients with PTSD asked to describe their traumatic event (Tucker et
al., 2000). A recent study suggests that this effect may not be limited to those with a psychiatric diagnosis.
In a cross-over study of 16 moderately obese (otherwise healthy) males, heart rate during a mental arithmetic
task administered after 6 months of citalopram was significantly lower than after treatment with placebo
(Ljung et al., 2001)
Other lines of evidence also support the hypothesis that SSRI’s are sympatholytic in humans. Time domain
heart period variability, a measure that can be used to assess the relative contribution of sympathetic and
parasympathetic tone to the heart, has been shown to be altered by SSRI’s. Increased measures of heart
period variability are generally associated with a lower proportion of sympathetic to parasympathetic
activity. Depressed patients have been shown to have lower heart period variability relative to their nondepressed counterparts (Carney et al., 1995; Krittayaphong et al., 1997). When an SSRI is used to treat
depression, heart rate variability increases in some studies (Balogh et al., 1993; Tucker et al., 1997). It is not
known, however, if heart period variability changes are secondary to the resolution of depressive symptoms
or are independent effects of SSRI’s.
The utility of SSRI’s in treating vasovagal syncope, also suggests that these agents have cardiovascular
stabilizing properties (Di Girolamo et al., 1999; Grubb et al., 1993; Grubb et al., 1994). Although, at this
time the pathophysiology of the syncopal episode is not entirely understood, certain types of syncope may be
initiated by a sympathetic surge that occurs in response to a physical or psychological stress (e.g. standing up
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or speaking in public). The ensuing forceful contractions of the cardiac ventricles can result in an
“overstretching” of the cardioventricular C fibers. This stretching may be similar to that which occurs during
a hypertensive episode and therefore may lead to compensatory sympathetic neuroinhibition. The resultant
withdrawal of sympathetic stimulation leads to peripheral vasodilation, bradycardia and ultimately fainting
(Grubb et al., 1993; Grubb et al., 1994). If SSRI’s modulate the initial sympathetic surge, the syncopal
episode could theoretically be avoided (indicative of the potential sympathetic stabilizing properties of
SSRI’s).
Evidence of the sympatholytic attributes of serotonergic compounds is also found in the animal literature
(Baum and Shropshire, 1975; Blatt et al., 1979; Lehnert et al., 1987; Rabinowitz and Lown, 1978). A
number of studies demonstrate that serotonergic stimulation in the brain causes inhibition of sympathetic
efferents to the heart. In animal models, increased brain serotonin substantially increases the threshold for
development of ventricular fibrillation during experimental coronary artery occlusion (Lehnert et al., 1987)
and during electrical stimulation at vulnerable periods in the cardiac cycle (Blatt et al., 1979). These effects
are thought to be mediated by alterations in sympathetic activity since stellectomy (but not vagotomy)
prevents these electrophysiological changes (Verrier, 1986). In these animal models, increases in brain
serotonergic neurotransmission, therefore, substantially inhibited the likelihood of serious ventricular
arrhythmias during cardiovascular stress (Antonaccio and Robson, 1973; Baum and Shropshire, 1975; Blatt
et al., 1979; Lehnert et al., 1987; Rabinowitz and Lown, 1978).
The SSRI that would be most likely to exhibit sympatholytic properties is unclear. Although all of the
currently available SSRI’s are effective in the treatment of depression, they do have varied clinical profiles.
Paroxetine is currently the only SSRI approved by the Food and Drug Administration for the treatment of
both generalized anxiety disorder and social anxiety disorder (although several of the other SSRI’s are likely
effective as well). Clinically, many feel that paroxetine is the most calming of the SSRI’s. For these reasons
we selected paroxetine for the preliminary studies described below and for the study proposed in this
application. Bupropion, although also an effective antidepressant and widely used to assist in the smoking
cessation attempt, would seem less likely to reduce physiological response to stress. Bupropion, the
mechanism of action of which is thought to be at least partially attributable to norepinephrine reuptake
inhibition (Ascher et al., 1995), is not know to treat conditions such as generalized anxiety disorder, social
phobia, and post-traumatic stress disorder (Pearlstein et al., 1997). Furthermore, bupropion is structurally
similar to a number of psychostimulants and unlike most SSRI’s, bupropion is associated with activating side
effects (e.g. agitation, insomnia).
Although a number of recent studies have not found that SSRI’s, used alone or in addition to nicotine
replacement therapy, increase smoking cessation rates (Blondal et al., 1999; Covey et al., 2002; Killen et al.,
2000; Niaura et al., 2002b),the SSRI’s may be effective in certain subsets of smokers. For example, several
analyses have found that fluoxetine may be effective when used in smokers with symptoms (even
subclinical) of depression (Blondal et al., 1999; Hitsman et al., 1999; Niaura et al., 1995). Further study is
therefore needed in order to better understand the effect of SSRI’s in certain sub-populations of smokers. If
SSRI’s are shown to reduce stress reactivity in smokers, studies assessing the effect of these agents in those
smokers who are highly reactive to stressful situations would be warranted.
iv. Summary.
In summary, exaggerated reactivity to mental stress tasks has been demonstrated to be associated with higher
mortality rates. Smoking combined with stress has been shown to increase reactivity to mental stress,
however it is unknown at this point whether such reactivity can be decreased using antidepressant therapy.
Although the treatment of choice to reduce smoking induced cardiovascular disease is clearly smoking
cessation, unfortunately many smokers are unwilling or unable to quit. Other approaches to reduce
cardiovascular disease may be appropriate in such individuals and several lines of evidence suggest that
SSRI’s may do so by decreasing cardiovascular reactivity to mental stress. However, that hypothesis has not
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yet been tested. If SSRI’s can be shown to reduce reactivity to mental stressors, they may have beneficial
effects on longer-term morbidity and mortality in smokers and potentially in other populations at increased
risk of CAD (e.g. elderly, people with established atherosclerosis). Since all antidepressants may not be
equivalent in their effects on cardiovascular stress response, the results of this and subsequent studies would
be useful in determining which antidepressants are most appropriate when treating depression in patients at
risk for cardiovascular disease. Additionally, since smokers with exaggerated responses to stress may be
more likely to relapse after a smoking cessation attempt, agents that decrease stress reactivity could
potentially increase long term smoking cessation in this population.
C. Preliminary Studies
Dr. Kotlyar, working with Dr. Golding, has investigated the role of serotonergic agents in modulating
sympathetic reactivity to mental and physical stress in several studies that have generated preliminary data
supporting the current hypothesis and using many of the methods proposed for this project.
In a pilot project, 5 subjects with a known history of significant coronary artery disease (as documented by a
history of Coronary Artery Bypass Grafting or Percutaneous Transluminal Coronary Angioplasty) were
enrolled into a parallel group, double-blind, placebo controlled study (Golding et al., 2002). Subjects were
randomized to receive one month of therapy with either 10 mg paroxetine daily (n=3) or matching placebo
(n=2) for 4 weeks. All subjects had no psychiatric diagnoses and all medications were maintained without
changes except that all subjects taking beta-blockers were converted to atenolol to avoid drug interactions
with paroxetine. Each subject was asked to give an impromptu speech prior to and after therapy during
which blood pressure, heart rate and plasma catecholamines were measured. Psychological comfort level
was assessed at the conclusion of each speech using the brief social phobia scale (Davidson et al., 1991) and,
upon completion of the study, by asking subjects to identify which of the two speeches caused less
discomfort. Cardiovascular parameters during the speech stressor (before and after treatment) are reported in
Table 2. Although the small sample size precludes any definitive conclusions from being drawn, subjects
treated with paroxetine but not with placebo had lower blood pressure, heart rate, plasma catecholamine
concentrations and BSPS score after treatment.
Table 2. Averaged cardiovascular and psychological responses during speech
Paroxetine Subjects (n=3)
Placebo Subjects (n=2)
Before Tx After Tx Difference
Before Tx After Tx
Difference
Plasma NE (ng/ml)
312
221
- 91
321
404
+ 83
*
156
149
-7
160
161
+1
SBP (mmHg)
*
DBP (mmHg)
87
79
-8
82
85
+3
*
HR (beats/min)
67
59
-8
61
62
+1
BSPS Score
4
2.3
-1.7
3
4.5
+1.5
SBP - Systolic blood pressure; DBP - Diastolic Blood Pressure; HR - Heart rate; NE – norepinephrine; BSPS
– Brief Social Phobia Scale
* Averaged cardiovascular response from 3 paroxetine subjects or 2 placebo subjects. Response for each
subject is the average of at least 10 measurements taken at 1 minute intervals.
A follow-up study, utilizing a cross over design in a similar population (patients with a known history of
significant CAD) also found similar results. Eight subjects received 4 weeks of paroxetine (10 mg daily) and
4 weeks of matching placebo in random order. As in the previous study, all subjects had no psychiatric
diagnoses and subjects on beta-blockers were converted to atenolol to avoid potential drug interactions. At
the conclusion of each month of treatment subjects were first asked to relax in a quiet room for 30 minutes
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during which blood pressure and heart rate were measured at one-minute intervals. After this relaxation
period, subjects were asked to give an impromptu speech during which BP and HR continued to be measured
at one-minute intervals. Cardiovascular reactivity was determined by comparing the difference in average
HR and BP during the stress task compared to average HR and BP while resting. As can be seen in Table 3,
increases in HR and BP were somewhat greater after placebo treatment than after treatment with paroxetine.
The effects of paroxetine were likely attenuated by treatment with the beta-blocker atenolol in 7 of the 8
subjects. We suspect that that the lower resting levels of HR and BP observed while subjects were on
paroxetine (relative to placebo) are due to subjects not being truly relaxed despite our attempts to get them to
do so. Simply being in a study during which they knew they would be asked to perform a stressful activity
was likely a stressor in itself. If this is indeed the case, we may be underestimating the actual effect of
paroxetine. In order to address this issue, an additional relaxation period, after the completion of all mental
stress tasks, has been added to the proposed study.
Table 3. Averaged cardiovascular and psychological responses during speech stressor (n=8)
Paroxetine Treatment
Placebo Treatment
Resting Stress
Difference
Resting Stress
Difference
SBP (mmHg)*
DBP (mmHg)*
HR (beats/min)*
121
64
55
149
77
58
+28
+13
+3
133
69
58
167
86
63
+ 34
+ 17
+5
SBP - Systolic blood pressure; DBP - Diastolic blood pressure; HR - Heart rate
* Averaged cardiovascular response from 8 subjects. Response for each subject is the average of at least 10
measurements taken at 1 minute intervals.
These preliminary studies provide evidence that paroxetine may reduce the physiological response to stress
and that the principal investigator has experience with the methodology proposed in this study.
Another study performed by Dr. Kotlyar evaluated the effects of 8 days of nefazodone treatment (at a target
dose of 400 mg/day given in 2 divided daily doses) on plasma catecholamine concentrations and platelet
aggregability during an orthostatic challenge in 7 healthy volunteers (Golding et al., 1999). This study found
that among subjects who became orthostatic (fall in DBP of 5 mm of Hg or more, HR increase by greater
than 20 beats per minute or near-syncope after 5 minutes of standing) plasma catecholamine concentrations
and platelet aggregability increased. Conversely, in subjects that did not become orthostatic, plasma
catecholamine concentrations and platelet aggregability were lower during the orthostatic challenge after
nefazodone therapy relative to pre-nefazodone levels. This suggests that nefazodone had sympatholytic
effects but only in a sub-population of subjects. These results could likely be explained by nefazodone’s
multiple mechanisms of action. In addition to its serotonergic effects, nefazodone is also an alpha1
antagonist. Antagonism of the alpha1 receptor can result in orthostasis, which would lead to compensatory
increases in catecholamine concentrations and a resultant increase in platelet aggregability. In the 3 subjects
that did not become orthostatic (possibly because they were less sensitive to the alpha blocking effects or
because they grew tolerant to these effects quicker than the other subjects), we hypothesize that the
serotonergic effects predominated and resulted in the apparent sympatholysis. Since this study was an addon investigation to a study assessing the effects of nefazodone on CYP450 enzyme activity, an alternative
agent could not be used. The proposed study, however will assess the effect of paroxetine, a drug with fewer
concurrent mechanisms of action that may confound the results.
Dr. Kotlyar also has experience in conducting research in smokers. During his postdoctoral fellowship, he
helped design and run a multi-center study assessing the effect of bupropion on the ability of smokers not
willing to quit smoking to reduce their daily nicotine usage. It was further assessed whether smoking
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reduction leads to cessation among this group of smokers. The results of this study have recently been
published in the American Journal of Medicine (Hatsukami et al., 2004b). After his arrival at the University
of Minnesota, Dr. Kotlyar initiated a pilot study evaluating the effects of desipramine on smoking
withdrawal symptoms. Additionally, Dr. Kotlyar is currently principal investigator on a pilot investigation
examining the effects of bupropion on stress reactivity during the smoking withdrawal period. Recruitment
for this study has just been completed and we are in the process of starting to analyze data. Dr. Kotlyar
therefore has experience in recruiting and studying the population selected in this proposal and has
experience with the methodology to be employed in conducting this research.
D. Research Design and Methods
In order to address the specific aims as described above, we plan on conducting the following clinical study.
We hypothesize that relative to placebo, paroxetine will decrease physiological response and will also
decrease subject’s perceived psychological discomfort during mental stress.
i. Study Design.
We plan on conducting a randomized, double-blind, placebo controlled crossover study in which 60 smokers
will receive one month of treatment with 20 mg of paroxetine and one month of treatment with placebo
(Figure 2).
Figure 2: Study Outline
Smokers
unwilling to quit
n=60
R*
A
N
D
O
M
I
Z
E
Placebo tx
1 month
n=30
Placebo tx
1 month
Paroxetine tx: 20 mg/day
1 month
n=30
Paroxetine tx: 20 mg/day
1 month
* The randomization will be stratified by gender and by level of nicotine dependence (FTND scores >6 and
< 6) so that there will be four equal sized subgroups of participants
After an initial screening visit in which subject eligibility will be assessed, subjects will be randomized to
receive treatment with either paroxetine given as a once daily 20 mg dose (10 mg daily for 1 week followed
by 20 mg once daily) or matching placebo. One month of treatment was selected since this is typically the
length of time required for paroxetine to exert its effects when used in the treatment of psychiatric disorders
(Schatzberg, 2002). After one month of treatment, subjects after abstaining from smoking overnight, will
return to the General Clinical Research Center (GCRC) for a visit at which mental stress testing will be
performed immediately after a subject has finished smoking a cigarette. At the conclusion of the mental
stress testing, subjects will receive a supply of the alternate treatment and will return to the GCRC after one
month at which time the mental stress testing will be repeated.
In order to determine whether a concentration response relationship exists between paroxetine plasma
concentrations and changes in physiological reactivity to mental stress, plasma will be collected at each visit
and will be analyzed for plasma paroxetine concentrations. Additionally both plasma nicotine and cotinine
concentrations will be measured. Cotinine has a half-life that is much longer than that of nicotine (Benowitz
et al., 2002) and is therefore an indicator of longer-term smoking than nicotine. Accordingly cotinine
concentrations will serve as verification that subjects had not significantly changed their smoking behavior
during the month of treatment. Since subjects were to have abstained from smoking the morning of the
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laboratory assessment, nicotine concentrations will likely be largely indicative of the amount of nicotine
obtained from the cigarette smoked during the laboratory session.
ii. Subjects
Volunteers for this study will be recruited through advertisement. Given that over 20% of the population
smokes, we do not anticipate difficulty in enrolling an adequate number of study subjects.
In order to be eligible for this study subjects must be:
1. Males or females between the ages of 18 and 65
2. Smoking at least 15 cigarettes per day for over a 1 year period
Exclusion criteria for this study will be:
1. Current unstable medical condition
2. Substance abuse within one year of beginning the study
3. Current use of any medications that in the opinion of the investigators might interfere with
measures to be studied (e.g. psychoactive medications, antihypertensives) or that would be
expected to interact with paroxetine (e.g. CYP2D6 substrates)
4. Subjects that have used any smoking cessation therapy during the past 3 months
5. Subjects that use any form of tobacco other than cigarettes
6. Subjects with a psychiatric diagnosis as assessed by the PRIME-MD
7. History of hypersensitivity to any selective serotonin reuptake inhibitor
8. Women who are pregnant or breast feeding
Additionally, only subjects not interested in quitting smoking over the following three-month period will be
enrolled in this study. Subjects that at the screening visit indicate any interest in quitting smoking will be
referred to appropriate resources available in the community in order to maximize their chances of
successfully quitting smoking.
iii. Procedures.
a) Screening visit. In order to assess subject eligibility all subjects, prior to being enrolled will undergo a
screening visit. At this visit, written informed consent will be obtained and inclusion / exclusion criteria will
be reviewed. Psychiatric diagnoses will be evaluated using the Primary Care Evaluation of Mental Disorders
(PRIME-MD). This scale can be administered quickly (average completion time of 8.4 minutes) to diagnose
five categories of psychiatric disorders (mood, anxiety, somatoform, eating and alcohol-related). Subjects
initially complete a 26 item questionnaire which is followed up (if necessary) with a structured interview.
Diagnoses, as determined by the PRIME-MD have been found to have good agreement with those made
independently by mental health professionals (Spitzer et al., 1994). Additionally, a physical exam and
routine blood work (i.e. complete blood count, chemistry panel, pregnancy test) will also be performed.
Subjects that qualify for this study will be randomized to receive either paroxetine, initiated at 10 mg once
daily for 1 week and then increased to 20 mg once daily or matching placebo. Subjects will return to the
GCRC in 1 week at which time the remainder of the medication will be dispensed, compliance will be
assessed via subject report and via pill count and adverse effects will be assessed. Subjects will be
contacted via telephone 1 week and 2 weeks after this visit to stress compliance and assess for side effects.
Subjects will also be telephoned the day prior to their assessment visit to remind them to bring any unused
medication to the visit.
b) First Assessment Visit. Subjects will continue to smoke normally until the evening prior to the day of
the study visit and will abstain from smoking until they arrive at the GCRC. Shortly after arrival at the
GCRC, smoking behavior during the previous week will be determined using the timeline follow-back
method (Gariti et al., 1998). Medication compliance will be assessed via subject report and via pill counts.
An indwelling catheter will then be inserted into an arm vein of the subject with normal saline being infused
at a rate sufficient to maintain the line. Prior to beginning the mental stress testing, blood will be drawn from
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the subject. Paroxetine concentrations will be analyzed from the blood sample and will be used to assess
whether there is a concentration response relationship between paroxetine and changes in mental stress
reactivity. Due to the high inter-individual variability in paroxetine pharmacokinetics, paroxetine
concentrations will not be used to assess compliance (DeVane, 2003). Subjects who take less than 80% of
scheduled medication doses either by self-report or as assessed by pill counts will be considered noncompliant and excluded from the analysis. Cotinine and nicotine concentrations will also be analyzed from
the plasma collected. Thirty minutes prior to the beginning of the mental stress testing, an automated blood
pressure machine will begin to record blood pressure readings at two-minute intervals and will continue to
do so until the conclusion of the study. Subjects will then be asked to relax in a quiet room for a 30 minute
period, at the conclusion of which blood will be drawn and will subsequently be used to measure plasma
catecholamine concentrations (epinephrine and norepinephrine). The measures obtained during this
relaxation period will be considered their “relaxed” measures. After the blood draw, subjects will be asked
to smoke a single cigarette of their usual brand. Immediately after they finish smoking the cigarette, subjects
will be presented with a scenario that could reasonably be expected to occur in their lives and which could be
expected to be somewhat stressful. Subjects will be asked to think about this scenario for a three-minute
period and will then give a three-minute speech addressing how they would handle the scenario in question.
The speech task used is based on previously published methods and has been found to increase stress in other
studies and our preliminary studies (al'Absi et al., 1997; Koo-Loeb et al., 2000). This speech will be
recorded and played back to the subject immediately after they finish speaking. This will mark the
conclusion of the speech stress task and the next task will be explained to the subject. During this task
subjects will be asked to perform a series of additions for the following 3 minutes. This math task has been
demonstrated to elicit strong physiological responses (al'Absi et al., 1997; al'Absi et al., 1998).
Blood, from which plasma catecholamine concentrations and plasma nicotine concentrations will be
measured, will be drawn 1.5 minutes into the subjects’ speech and 1.5 minutes into the mental arithmetic
task. Blood pressure will be recorded at 1 minute intervals throughout the stress testing procedure.
Measures obtained during the mental stress tasks will be considered the “stress” measures. After filling out
questionnaires assessing symptoms of smoking withdrawal and psychological discomfort, a second 30
minute relaxation period will ensue during which blood pressure will continue to be monitored. The entire
procedure is expected to take approximately 3 hours. Figure 3 summarizes the procedures at each
assessment visit.
Figure 3. Outline of Each Assessment Day
Period 2
Period 1
Period 3
Period 4
Public Speaking Task
30 min.
relaxation
B, Q
3 min.
preparation
B
3 min.
speech
B
3 min.
playback
3 min. mental
arithmetic task
B
30 min.
relaxation
Q
B = blood draw
Q = questionnaires
Questionnaires administered at both of the time-points indicated above include the a) State Trait Anxiety
Inventory; b) Audience Anxiousness Scale; c) Subjective Symptoms Scale; d) Minnesota Nicotine
Withdrawal Scale. The Beck Depression Inventory and the Fagerstrom Test for Nicotine Dependence will
only be administered at the first time-point.
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Blood pressure and heart rate measurements will occur at 2 minute intervals during period 1 and period 4.
Blood pressure and heart rate measurements will occur at 1 minute intervals during period 2 and period 3.
After conclusion of the mental stress testing procedures, subjects will be dispensed medication such that they
receive opposite treatment to that which was received during the first month and will be scheduled to return
to the GCRC after 1 week (to assess compliance and adverse effects) and 1 month of therapy (to repeat
mental stress testing). A washout period should not be necessary since paroxetine’s half-life is
approximately 24 hours and steady state concentrations should be achieved within 1 week. One month
should therefore be sufficient time for any effects of paroxetine to wear off and therefore no carry over
effects should exist.
c). Second Assessment Visit. At the second assessment visit, mental stress testing procedures (as
described above) will be repeated. The procedure will be identical in most respects; however, the speech to
be delivered will be on a different topic. In order to minimize differences that may occur as a result of
circadian variation, mental stress testing during the second visit will occur at the same time of day as during
the first visit, and for women, during the same phase of the menstrual cycle.
iv. Outcome Measures.
To assess whether paroxetine has an effect on physiological or psychological response to mental stressors the
following variables will be used to answer each specific aim of the study (Table 5).
Table 5. Variables
Outcome Measures
Physiological Outcome Measures:
Systolic Blood Pressure
Diastolic Blood Pressure
Heart rate
Plasma norepinephrine concentrations
Plasma epinephrine concentrations
Psychological Discomfort Outcome Measures:
State Trait Anxiety Inventory
Audience Anxiousness Scale
Subjective State Scale
Control Variables
Between-subject level variable (measured once)
Gender
Fagerstrom Test for Nicotine Dependence
(FTND)
Within-subject level variables (measured at each
assessment visit)
Plasma nicotine concentration
Plasma cotinine concentration
Plasma paroxetine concentrations
Number of cigarettes smoked in week prior to
assessment
Beck Depression Inventory score
The effect of drug therapy on physiological reactivity to mental stress tasks (specific aim #1) will be assessed
based on measurement of blood pressure (systolic and diastolic), heart rate, plasma norepinephrine and
plasma epinephrine concentrations. During each of the assessment visits, changes in physiological measures
will be calculated by subtracting the “relaxed” values from the “stressed” values. The “relaxed” values will
be calculated based on the average of the measurements obtained during each of two relaxation periods (see
Figure 3, periods 1 and 4). The “stressed” values will be calculated based on the average of the
measurements obtained during the two mental stress tasks (see Figure 3, periods 2 and 3). The change
between values obtained during the mental stress tasks and the lower of the two relaxation periods will
represent the subject’s reactivity to mental stress. The reactivity will then be compared between the drug and
placebo conditions.
The plasma norepinephrine assay procedure to be used is a modification of the procedure reported by Wang
et al (Wang et al., 1999) using extraction kits acquired through ESA Inc. It involves extraction of
catecholamines from 1.0 ml of plasma with activated alumina, injection of the acid extract onto a reverse
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phase C-18 column and separation with a mobile phase consisting of 8.0% acetonitrile, 16% methanol and
100 mM phosphate buffer pH to 3.0 pumped at 1 mL/min. The amines are detected on an ESA II coulochem
electrochemical detector. The lower limit of quantitation is 10 pg/ml in plasma. The increases in plasma
norepinephrine and epinephrine concentrations during the mental stress tasks relative to pre-stress values will
be compared between treatment conditions. Plasma paroxetine concentrations will be analyzed using high
performance liquid chromatography with ultraviolet detection via methods similar to those reported by
Knoeller et al (Knoeller et al 1995).
To assess psychological discomfort during the mental stress tasks (specific aim #2) the following forms will
be used: a) State form of the State Trait Anxiety Inventory (Spielberger, 1983), which assesses 20 anxietyrelated symptoms with reference to how the individual feels ‘at the moment’ asking subjects to rate each
symptom on a scale of 1 to 4. The developers report high internal reliability of this questionnaires (α=0.91);
b) Audience Anxiousness Scale (AAS) (Leary, 1983) as modified by Abrams et al (Abrams et al., 2001)
which was designed to assess anxiety symptoms when speaking or performing before an audience by asking
10 questions regarding worries or thoughts that occur in relation to a public speaking task. This instrument
has been used to assess anxiety during an unrehearsed speaking task and has shown differences in anxiety
levels between control and treatment conditions (Abrams et al., 2001; Abrams et al., 2002). The internal
reliability of this questionnaire was as follows: alphas of 0.87 for the Pre-Speech AAS, and 0.88 for the PostSpeech AAS (Abrams et al., 2002); c) The Subjective State Scale, is an instrument that has been used and
found sensitive to effects of laboratory-administered stressors (al'Absi et al., 2002; al'Absi et al., 2003). This
instrument assesses activation and distress by inquiring the degree to which each of 24 words/symptoms
applied to how subjects felt during the stress task. The subscales of this measure, positive affect and distress,
have been found to be reliable (alphas are 0.85 and 0.82, respectively) (al'Absi et al., 2003). To assess
symptoms of tobacco withdrawal the Minnesota Nicotine Withdrawal Scale will be used (Hughes and
Hatsukami, 1998; Hughes and Hatsukami, 1986; Hughes, 1992). This scale asks the subject to rate on a
scale of 0 to 4 the extent to which they are experiencing each of 8 nicotine withdrawal symptoms.
v. Control variables and stratified randomization.
A number of characteristics that could potentially confound or modify any association between drug
treatment and response to stress (i.e., outcome measures) will be controlled for in our analyses. At the
subject level, these are a) gender and b) degree of nicotine dependence (assessed via the Fagerstrom Test for
Nicotine Dependence (FTND). Within-subjects, these include a) presence of depressive symptoms (as
assessed by Beck Depression Inventory [BDI] score); b) plasma paroxetine concentrations, c) plasma
nicotine concentrations, d) plasma cotinine concentrations and e) average number of cigarettes smoked per
day in week prior to assessment.
The FTND is a six-item questionnaire commonly used to assess degree of nicotine dependence and is closely
related to biochemical indices of heaviness of smoking (Heatherton et al., 1991). A score of 6 or greater on
the FTND has been used an indicator of a highly dependent smoker (Fagerstrom et al., 1996; Heatherton et
al., 1991)). The BDI (Beck and Steer, 1984) is an instrument commonly used to assess symptoms of
depression in studies assessing the effects of depression on cardiovascular outcome. BDI scores of 10 or
greater in patients with CAD have been associated with poor outcomes in patients with cardiovascular
disease.
To control for subject-level variables, we will stratify recruitment by gender and FTND, so that equal
numbers of men and women and an equal number of those with high nicotine dependence (FTND>6) and
low nicotine dependence (FTND < 6) will be enrolled. Randomization will also be stratified for these four
subgroups. Adjustment for within-subject variables will be through statistical modeling.
vi. Statistical Analyses and Power Calculations.
The randomization will be stratified by gender and FTND level (score of 6 or greater vs. less than 6), so that
there will be four equal sized subgroups of participants. Although the study is not powered to compare these
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subgroups, the balance will allow us to examine interactions between these factors and the treatment
conditions.
The baseline distribution of demographics, smoking-related characteristics, outcome measures and
covariates will be summarized by descriptive statistics. In this crossover study, physiological outcome
measures (see table 5) will be assessed at rest and during the administration of mental stressors (see Figure
3) with change from resting value being the endpoint. Specifically, we will test if the change occurring
during the mental stress tasks in the placebo condition is equivalent to the change in the paroxetine
condition. The psychological discomfort outcome measures will be assessed prior to and after the mental
stress tasks with questionnaire score being the endpoint. Specifically, we will test if the level of
psychological distress prior to and during the mental stress tasks in the placebo condition is equivalent to
that in the paroxetine condition.
We will fit random-effect generalized linear models to compare responses to paroxetine and placebo within
participants, where participants will be treated as the random effect (Diggle et al., 1994) . This will allow us
to examine repeated measurements and interactions of the treatment conditions with covariates at the
participant level (i.e. gender, FTND score), as well as with covariates at the period level (i.e. plasma
nicotine concentrations, plasma cotinine concentrations, plasma paroxetine concentrations, number of
cigarettes smoked in week prior to assessment, BDI score). The analysis will be performed using SAS Proc
Mixed.
Sample size estimates were based on predicted changes in systolic blood pressure, which is the primary
hypothesis. Based on previous work and literature values, we estimate that after short term smoking
abstinence average systolic blood pressures during a mental stress challenge will increase by approximately
25 mm Hg with a standard deviation of approximately 10 (Jern et al., 1995; Perkins et al., 1986; Rozanski et
al., 1988).(Jern et al., 1995; Rozanski et al., 1988). If paroxetine were to decrease the change in systolic
blood pressure by 1/5 (i.e. approximately 5 mm Hg) a sample size of n = 60 will provide power of greater
than 0.80 to detect such a difference with two-tailed α = .05. Subjects who drop out prior to completing the
entire study will be replaced to ensure that the order of treatment remains equally balanced and recruitment
will continue until 60 subjects have completed the study. Assuming a 20% attrition rate, we anticipate
enrolling approximately 75 subjects to ensure that 60 complete all study visits. Adverse event information
will be collected from all randomized subjects, regardless of whether they complete the study or not.
Power estimates for other outcome measures based on power of 0.80, α = 0.05 and n = 60 are summarized
in table 6. Within subject standard deviations are estimated using literature values and our preliminary data
(Abrams et al., 2001; al'Absi et al., 2003; Jern et al., 1995; Perkins et al., 1986).
Table 6: Minimum detectable differences in outcome measures based on n=60
Minimum Detectable Estimated within subject
Outcome Measure
Difference
Standard Deviation
Physiological Outcome Measures:
Systolic Blood Pressure
5.2 mmHg
10
Diastolic Blood Pressure
2.2 mmHg
4.2
Heart rate
7.7 bpm
14.7
Plasma norepinephrine concentrations
24.7 pg/ml
53
Plasma epinephrine concentrations
7.9 pg/ml
15.1
Psychological Discomfort Outcome Measures:
State Trait Anxiety Inventory
Audience Anxiousness Scale
Subjective State Scale
Pre-Stress
Post-Stress
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3.6
3.8
6.9
2.1
2.3
4.0
4.5
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vii. Potential Difficulties/Limitations.
A number of potential difficulties could arise in carrying out this study. One potential limitation is that since
smokers, during the study, will be allowed to smoke cigarette as they normally would, different amounts of
nicotine (or other ingredients in cigarettes which might potentially affect reactivity) will be inhaled by
different subjects. We are using a cross-over design in order to reduce such variability.
There is the possibility that paroxetine will have an effect on smoking behavior during the month of
treatment and that such effects will alter physiolgoical reactivity to mental stress tasks. A number of studies,
however, have looked at the effect of SSRI’s on smoking behavior and have not generally found them to be
effective in reducing smoking in smokers without depression (Blondal et al., 1999; Covey et al., 2002;
Killen et al., 2000; Niaura et al., 2002b). Furthermore, a timeline follow-back assessment of smoking will be
used to determine if changes occurred in smoking behavior and the number of cigarettes smoked during the
week prior to each assessment has been added as a covariate in the data analysis plan in order to control for
any differences in amount smoked that may occur as a result of study medications. Additionally, we will
measure plasma cotinine concentrations to confirm that subjects have not altered their smoking behavior and
plasma nicotine concentrations to determine whether the amount of nicotine obtained during the laboratory
session affects stress response.
There is the possibility that a learning effect will be observed between the two stressors. Previous studies in
the literature (e.g. al’Absi et al 1997) and our preliminary studies have assessed stress reactivity on two
occasions and have found that reactivity to mental stress tasks is relatively stable over time. We therefore do
not anticipate that this will be a significant problem. We do plan to assess whether a learning effect is
present and since the ordering of treatments in the crossover will be balanced, we will be able to include a
time effect in the statistical analysis if there is evidence that it exists.
We anticipate that a certain number of subjects will not tolerate paroxetine therapy or drop out for other
reasons. Since attrition in a cross-over design is problematic with respect to data analysis, we will replace
subjects that drop-out or are determined to be non-compliant until 60 subjects have completed the study.
The role of strategies aimed at reducing harm in smokers unwilling to quit is currently being debated in the
tobacco use disorder literature. The idea of “harm reduction” is likely an issue that will continue to be
debated for some time, however the line of research proposed in this project will provide valuable
information regardless of the consensus that is ultimately reached on this broader issue. This and future
studies are important in providing insight regarding a mechanism by which smoking may contribute to
smoking related cardiovascular disease. Ascertaining the effect of various antidepressants on physiological
reactivity to stress will be important not only as it relates to smokers but also to other patients at increased
risk of cardiovascular morbidity and mortality such as those with symptoms of depression and the elderly
among others. We feel that this area is therefore worthy of more research.
viii. Subsequent Projects.
Ultimately, if antidepressants are demonstrated to reduce cardiovascular response to stress, studies assessing
whether this has any benefit on morbidity will be conducted. Additionally, demonstrating this effect of
antidepressants would lead to studies assessing whether smoking relapse rates can be reduced in those who
report smoking in response to stressful situations.
The next project in this line of research, expected to be initiated in year 5 of the project period, would
depend partly on the results obtained in this proposed study. If it is found that paroxetine does decrease the
physiological response to mental stress, the subsequent study will expand on these findings in order to
determine whether reducing stress response can also affect smoking behavior. Such a study would assess
whether paroxetine, in smokers highly reactive to stress, decreases smoking urges during stressful periods
thereby increasing smoking cessation rates. Sub-analyses of data obtained from the current proposal would
suggest which populations of smokers would be most likely to respond to paroxetine therapy and therefore
be the focus of the subsequent study. Another important subsequent project would be to establish the effect
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of bupropion on physiological stress response during cigarette smoking. Although one would not expect that
bupropion, due to its pharmacology and clinical effects, would be as likely to decrease stress response as
paroxetine, the efficacy of bupropion in increasing smoking cessation rates would warrant examining this
question. Comparing the results of a study assessing bupropion and one assessing paroxetine will allow
comparisons to be made between agents based on their mechanisms of action.
More advanced techniques of analyzing cardiovascular reactivity learned during the training portion of this
grant will allow for a more in-depth evaluation of the physiological effects of antidepressants in subsequent
studies. Longer-term goals of this line of research would include more in-depth evaluations of
mechanistically distinct antidepressant agents (i.e. serotonergic vs. noradrenergic) on stress response,
smoking behavior and long-term cardiovascular health. Ultimately, the long-term cardiovascular effects of
agents that are proven to decrease response to stress will also be assessed in smokers and in other
populations at increased risk of cardiovascular morbidity (e.g. those with symptoms of depression, the
elderly or those with established CAD).
ix. Proposed timeline.
Research Related Activities
Study set – up
Recruitment
Analysis of plasma samples
Data Analysis
Abstract / manuscript
preparation
Begin subsequent project
Prepare R01
Year 1
Year 2
Year 3
Year 4
Year 5
Year of Grant
E. Human Subjects.
i. Risks to the Subjects.
This double-blind, placebo controlled, crossover study, in which subjects will receive one month of
paroxetine and one month of placebo treatment, will involve a total of 6 visits for each subject. The study
visits will consist of a screening visit, 2 visits at which physiological and psychological assessments will be
made during laboratory induced mental stress tasks (public speaking and mental arithmetic) and 2 visit at
which medication is picked up and adverse effects are assessed. Subjects will be generally healthy smokers
between the ages of 18 and 65 (specific inclusion / exclusion criteria are described in the Research Design
and Methods section).
Paroxetine is currently approved for marketing in the United States for the treatment of major depressive
disorder, obsessive compulsive disorder, panic disorder, social anxiety disorder, generalized anxiety disorder
and post-traumatic stress disorder. It is among the most commonly prescribed medications in the United
States and has been shown to be generally safe. Side effects commonly associated with paroxetine include
headache, somnolence, nausea, tremor, dry mouth and sexual dysfunction. In order to minimize side effects,
subjects will take 10 mg of paroxetine for 1 week before increasing the dose to 20 mg per day. Subjects will
come in 1 week after starting medication and will be called 2 weeks and 3 weeks after starting medication in
order to assess adverse effects.
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Although this study can be expected to cause some psychological discomfort to patients, the stressors used
are comparable to those that patients may encounter in everyday life and therefore should not cause an undue
risk to patients. The use of placebo is justified since it is not presently known whether administrating
paroxetine provides any benefit to subjects and because subjects are not being treated for any condition in
this study. A total of 60 subjects will be assessed in this study.
ii. Adequacy of Protection Against Risk.
This study will be submitted for approved by the University of Minnesota Institutional Review Board. The
study will be explained to all subjects and all subjects will have an opportunity to ask any questions prior to
signing an informed consent form. No study related procedures will take place until an informed consent
form has been signed. Subjects will be paid $230.00 for completion of this study. Since this study will
involve a total of 6 visits, three of which will take over 2 hours each, this amount should not be considered
coercive and is given as compensation for the subject’s time. In order not to discourage smokers from
quitting, only smokers not planning to quit during the duration of the study will be enrolled. At the
conclusion of the study, smokers will be encouraged to quit smoking and will be provided information on
various techniques available to help smokers quit. They will also be informed of services in the community
that assist with the smoking cessation attempt.
iii. Potential Benefits of the Proposed Research.
This study (and other studies in this line of research) will provide insight regarding a potential mechanism of
smoking induced cardiovascular response and will provide data regarding potentially novel treatment options
to reduce cardiovascular risk in smokers.
iv. Importance of the Knowledge to be Gained.
Smoking is a well-established contributor to cardiovascular morbidity and mortality, leading to an estimated
148,000 deaths in the United States annually. Although a number of potential mechanisms are thought to
contribute to smoking induced cardiovascular disease (e.g. acceleration of the development of
atherosclerosis, predisposition to thrombus formation, predisposition to myocardial ischemia), a potential
mechanism that has not received adequate research is the physiological response to stress in combination
with smoking. A better understanding of this under-studied mechanism of smoking related cardiovascular
disease and potential therapies for reducing this risk factor may ultimately lead to decreased cardiovascular
disease in smokers. Since paroxetine is a commonly used, well-tolerated medication, the risks associated
with its administration are reasonable in light of the anticipated knowledge to be gained.
v. Inclusion of Women.
We are planning to recruit an equal number of men and women in this study. If during the course of the
study, we find that the number of women enrolling is substantially lower than the number of men, we will
adjust our advertising strategy such that women will be specifically recruited in advertisements.
vi. Inclusion of Minorities.
Recruitment of minorities will be a priority. The metropolitan area is sufficiently large in population to
ensure an adequate sample of subjects with diverse demographic and ethnic backgrounds. According to the
2000 census, in the Twin Cities (Minneapolis and St. Paul) metropolitan area, minorities represented
approximately 15% of the population (Black=5.9%, Asian=4.6%, Hispanic=3.6%). We will strive to exceed
these numbers as much as possible (see attached table). Every attempt will be made to enhance the
recruitment of minorities. Some of our advertisements will be aimed at minority participation.
vii. Inclusion of Children.
We will enroll smokers over the age of 18 in this study. Children less than 18 years of age will be excluded
from the study. Addressing smoking by youth, a very important issue, is best done by studies that focus
specifically on the youth population. The stress tasks used in this study (public speaking task, mental
arithmetic) likely would not have the same stress inducing effects in younger children. Furthermore, the
safety of paroxetine in those under the age of 18 has recently been questioned by the Food and Drug
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Administration. For these reasons, we do not believe that it would be appropriate to enroll children under the
age of 18 in this study.
viii. Data and Safety Monitoring Plan.
The principal investigator in conjunction with the study physician will be responsible for monitoring adverse
effects. At each visit and phone contact subjects will be asked whether they have had any side effects. Any
positive response will be followed up with questions regarding details of what the adverse effect was and the
severity. Therapy will be discontinued if the subject reports any side effect of greater than moderate severity
or if the subject develops any clinical symptoms that in the opinion of the investigators would warrant drug
discontinuation. Participation in the study would also be discontinued if during the course of the study the
subject develops a significant medical condition (regardless of whether it can be attributed to the study drug)
or is initiated on medication that can be expected to interact with paroxetine (e.g. drug metabolized by the
cytochrome P450 2D6 isoenzyme). The subject has the option of discontinuing their participation at any
time for any reason. Any adverse effects not commonly associated with paroxetine administration or any
serious adverse events will be reported to the IRB.
To ensure confidentiality, all subjects enrolled in the study will be assigned a study identification code.
These codes will be used on all study related data collection forms except for those on which the use of
personal identifiers is mandatory (e.g. informed consent form). Forms that link the name of the participant
and the subject identification code will be kept in a locked cabinet inside a locked office or in an electronic
file stored on password protected secure computer servers that meet HIPPA guidelines for ensuring patient
confidentiality. Access to subject identifiable information will be limited to those that require this
information such as the principal investigator or others who have direct contact with study subjects (e.g.
study coordinator).
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Targeted/Planned Enrollment Table
This report format should NOT be used for data collection from study participants.
Study Title: Smoking, antidepressants and response to mental stress
Total Planned Enrollment: 60
TARGETED/PLANNED ENROLLMENT: Number of Subjects
Sex/Gender
Ethnic Category
Females
Hispanic or Latino
Males
Total
2
1
3
Not Hispanic or Latino
28
29
57
Ethnic Category Total of All Subjects*
30
30
60
American Indian/Alaska Native
1
2
3
Asian
2
1
3
Native Hawaiian or Other Pacific Islander
0
0
0
Black or African American
3
2
5
24
25
49
Racial Categories
White
Racial Categories: Total of All Subjects *
30
30
60
*The “Ethnic Category Total of All Subjects” must be equal to the “Racial Categories Total of All Subjects.”
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F. Vertebrate Animals.
Not Applicable
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PHS 398/2590 (Rev. 05/01)
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Principal Investigator/Program Director (Last, first, middle):
Kotlyar, Michael
Zevin S, Saunders S, Gourlay SG, Jacob P, Benowitz NL (2001). Cardiovascular effects of carbon
monoxide and cigarette smoking. J Am Coll Cardiol 38:1633-8.
H. Consortium / Contractual Arrangements
Not Applicable
I. Consultants
Not Applicable
PHS 398/2590 (Rev. 05/01)
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