Effect of Galantamine on Smoking Abstinence

Galantamine, an FDA-approved treatment for Alzheimer's disease, is used to treat cognitive
impairment by enhancing acetylcholine through inhibition of the enzyme, acetylcholinesterase.
We propose an open-label pilot feasibility study of short-term (6 weeks) treatment with
galantamine.

Sixteen chronic smokers will undergo a validated procedure for screening new medications.
Following an initial 4-week drug run-up phase (8mg daily of galantamine-ER), medication dose
will be increased to 16 mg daily of galantamine-ER during the fifth and sixth weeks of the
study. At the beginning of Week 6, smokers will receive brief counseling and make a 7-day
quit attempt.

Following completion of the study, participants will be offered standard smoking cessation
treatment. Subjects will perform a working memory task (Visual/Spatial N-Back), a sustained
attention task (Continuous Performance Task; CPT), a recall memory task (Word Recognition), a
cognitive flexibility task (Wisconsin Card Sort Test), and a response inhibition task (Stop
Signal Task). The primary outcome is the ability to remain abstinent during a 7-day quit
attempt. Secondary outcomes include change in cognitive performance, adherence, and side
effects.

This pilot study will provide information about the role of the cholinergic system during
brief abstinence and whether enhancing acetylcholine reduces abstinence-induced cognitive
symptoms that promote smoking relapse. Information obtained in this study may further
establish cognitive performance measures as endophenotypes for nicotine dependence.

Inclusion Criteria:

1. Smokers who are between 18 and 60 years of age who self-report smoking at least 10
cigarettes (menthol and non-menthol) per day for at least the last 6 months.

2. Healthy as determined by the Study Physician, based on a medical evaluation including
medical history and physical examination, and psychiatric evaluation.

3. Capable of giving written informed consent, which includes compliance with the
requirements and restrictions listed in the combined consent and Health Insurance
Portability and Accountability Act (HIPAA) form.

4. Women of childbearing potential must consent to use a medically accepted method of
birth control while participating in the study (e.g., condoms and spermicide, oral
contraceptive, Depo-provera injection, contraceptive patch, tubal ligation).

Exclusion Criteria:

1. Smoking Behavior

- Use of chewing tobacco, snuff, and/or snus.

- Current enrollment in a smoking cessation program, or use of other smoking
cessation medications in the last month or plans to do either in the next 2
months.

- Provide a carbon monoxide (CO) breath sample reading less than 10ppm at Medical
Screening or Baseline visit.

2. Alcohol/Drugs

- Lifetime history of substance abuse (other than nicotine) and/or currently
receiving treatment for substance abuse (e.g., alcohol, opioids, cocaine,
stimulants, Phencyclidine (PCP), benzodiazepines, or study prohibited
medications/recreational drugs) as determined by self-report during the phone
screen and/or through the MINI during the Medical Screening.

- Current alcohol consumption that exceeds 25 standard drinks/week over the past 6
months.

- Providing a breath alcohol concentration (BrAC) reading of greater than or equal
to 0.01 at Medical Screen or Baseline sessions.

- A positive urine drug screen for cocaine, amphetamines, methamphetamines,
benzodiazepines, PCP, methadone, barbiturates, and opiates at the Medical
Screening, Baseline visit, and Testing days.

3. Medical

- Women who are pregnant, planning a pregnancy in the next 3 months, or lactating;
all female subjects of child-bearing potential shall undergo a urine pregnancy
test prior to enrollment and must agree in writing to use an approved method of
contraception. Pregnancy tests will be conducted at the Medical Screening,
Baseline visit, and Testing days.

- Diagnosis of Alzheimer's Disease or dementia.

- Current treatment of cancer or diagnosed with cancer (except basal cell
carcinoma) in the past 6 months.

- Liver/kidney failure, peptic ulcer disease, benign prostate hypertrophy

- Asthma or chronic obstructive pulmonary disease (COPD)

- History (last 6 months) of abnormal heart rhythms, tachycardia and/or
cardiovascular disease (stroke, angina, heart attack).

- Serious or unstable disease within the past 6 months, as determined by the Study
Physician.

- Any impairment (physical and/or neurological) including visual or other
impairment preventing cognitive task performance.

- Uncontrolled high blood pressure (systolic>150 or diastolic>90)

- Hearing impairment, significant hearing loss (more than 20% in either ear),
cochlear implants, or bi-lateral hearing aids.

- History of brain injury.

- History of epilepsy or a seizure disorder.

- Color Blindness.

- Low or borderline intellectual functioning - determined by receiving a score of
less than 90 on the Shipley Institute of Living Scale (SILS) which correlates
with the Wechsler Adult Intelligence Scale-Revised (WAIS-R) Estimated
Intelligence Quotient (IQ) Test (administered at Medical Screening).

4. Psychiatric Exclusion (as determined by self-report on phone screen and/or through
MINI during Medical Screening)

- Current diagnosis of major depression. Persons with a history of major
depression, in remission for 6 months or longer, are eligible, provided they are
not excluded based on medications (below).

- Suicide risk score on MINI greater than 0.

- History or current diagnosis of schizophrenia, psychosis, or bipolar disorder.

- Current or past hypomanic/manic episode.

- Current or history of a diagnosis of Attention-Deficit/Hyperactivity Disorder
(ADHD).

5. Medication

- Current use, recent discontinuation (within the last month) of any form of
smoking cessation medications (i.e., Zyban, Wellbutrin, Wellbutrin
sustained-release (SR), Chantix, nicotine replacement therapy).

- Current use, recent discontinuation (within the last 60 days) or planned use of
the following medications:

- Anti-anxiety or panic disorder medications.

- Anti-psychotic medications.

- Mood-stabilizers (Lithium, Lamictal/lamotrigine, Neurontin/gabapentin,
Topamax/topiramate, valproic acid, Tegretol/carbamazepine)

- Anti-depressants (e.g., Wellbutrin, monoamine oxidase inhibitor (MAOIs),
selective serotonin reuptake inhibitor (SSRIs), tricyclic antidepressants).

- Prescription stimulants (e.g., Provigil, Ritalin, Adderall).

- Systemic Steroids (e.g., Prednisone).

- Current use (or use in the past 60 days) of:

- Alzheimer's disease medications (e.g., Acetylcholinesterase inhibitors (ACIs),
Aricept/donepezil, Exelon/rivastigmine, Tacrine, or memantine).

- Parkinson's disease medications(e.g., Cogentin/benztropine).

- Irritable bowel syndrome medication (e.g., Dicylomine/Bentyl).

- Heart medications (e.g., quinidine or Procardia/nifedipine).

- Peptic ulcer disease medication (e.g, Zantac/ranitidine).

- Muscle relaxants (e.g., Soma/carisoprodol, Anectine/succinylcholine).

- Anti-fungal medication (e.g., Nizoral/ketoconazole).

- Anti-seizure medications (e.g., Ativan, Banzel, Carbatrol, Dilantin, Lamictal,
Gabitril, Lyrica, Neurontin, Tegretol, Topamax).

- COPD medication (e.g., Atrovent/Ipratropium Bromide).

- Blood pressure medication (e.g., Inversine/Mecamylamine).

- Urinary retention medications (Duvoid/bethanechol, Proscar/finasteride,
Avodart/dutasteride, Dibenzyline/phenoxybenzamine, Regitine/phentolamine).

- Eye medication (e.g., Atropine).

- Daily use of:

- Opiate-containing medications for chronic pain (Duragesic/fentanyl patches,
Percocet, Oxycontin).

- Medication for asthma (albuterol, Serevent, Combivent, Advair, Flovent, Azmacort,
Symbicort).

- Known allergy to study medication.

- Participants shall be instructed to refrain from using any study prohibited drugs
(note - participants are allowed to take prescription medicines not in the
exclusion list) throughout their participation in the study.

6. General Exclusion

- Current enrollment or plans to enroll in another research program in the next 2
months.

- Any medical condition, illness, disorder, or concomitant medication that could
compromise participant safety or treatment, as determined by the Principal
Investigator and/or Study Physician.

- Inability to provide informed consent or complete any of the study tasks as
determined by the Principal Investigator.

- Completion of cognitive testing in studies in our center within the last 6
months.

- Able to effectively communicate in English (reading, writing, speaking).

- Missing 2 or more consecutive sessions, or 3 or more sessions during the
medication period.

- Missing 2 or more consecutive doses during the medication period.

- Missing 3 or more doses throughout the medication period.