Approach-avoidance modification as an add-on in smoking cessation: A randomized-controlled study

How We Lost 90% of Participants on a Bad Bet: Results from a Pilot Randomized Controlled Trial on Cognitive Bias Modification in Problem Gamblers

Whilst opportunities to participate in gambling have increased, access to support for problem gamblers is lacking behind. This lack of balance calls for improved and accessible intervention methods. The present double-blind randomized controlled trial (RCT) explored the effectiveness of two interventions targeting automatic cognitive processes, known as Attentional Bias Modification (AtBM) and Approach Bias Modification (ApBM). It was hypothesized these interventions would reduce gambling behavior and reduce or reverse targeted biases. Participants (N = 331) were community-recruited Flemish (35%) and Dutch (65%) adult problem gamblers motivated to reduce or stop their gambling who received either six sessions of active training (AtBM or ApBM) or of the corresponding sham-training (sham-AtBM or sham-ApBM). Due to high attrition rates (90.1% up to the intervention phase) the study was terminated before completion, since it would greatly limit the validity of any results. A post hoc qualitative study was performed on a subset of participants to gain insight into contributing factors for the high attrition rate. Issues negatively impacting participants' motivation to complete the program were identified, as well as elements of the program that received approval. The results from this study provide a first insight into the potential of the use of online cognitive bias modification (CBM) interventions in problem gambling (PG). Suggestions and directions for future studies are discussed.

How pre-processing decisions affect the reliability and validity of the approach-avoidance task: Evidence from simulations and multiverse analyses with six datasets

Reaction time (RT) data are often pre-processed before analysis by rejecting outliers and errors and aggregating the data. In stimulus-response compatibility paradigms such as the approach-avoidance task (AAT), researchers often decide how to pre-process the data without an empirical basis, leading to the use of methods that may harm data quality. To provide this empirical basis, we investigated how different pre-processing methods affect the reliability and validity of the AAT. Our literature review revealed 108 unique pre-processing pipelines among 163 examined studies. Using empirical datasets, we found that validity and reliability were negatively affected by retaining error trials, by replacing error RTs with the mean RT plus a penalty, and by retaining outliers. In the relevant-feature AAT, bias scores were more reliable and valid if computed with D-scores; medians were less reliable and more unpredictable, while means were also less valid. Simulations revealed bias scores were likely to be less accurate if computed by contrasting a single aggregate of all compatible conditions with that of all incompatible conditions, rather than by contrasting separate averages per condition. We also found that multilevel model random effects were less reliable, valid, and stable, arguing against their use as bias scores. We call upon the field to drop these suboptimal practices to improve the psychometric properties of the AAT. We also call for similar investigations in related RT-based bias measures such as the implicit association task, as their commonly accepted pre-processing practices involve many of the aforementioned discouraged methods. HIGHLIGHTS: • Rejecting RTs deviating more than 2 or 3 SD from the mean gives more reliable and valid results than other outlier rejection methods in empirical data • Removing error trials gives more reliable and valid results than retaining them or replacing them with the block mean and an added penalty • Double-difference scores are more reliable than compatibility scores under most circumstances • More reliable and valid results are obtained both in simulated and real data by using double-difference D-scores, which are obtained by dividing a participant's double mean difference score by the SD of their RTs.

Sadness-Based Approach-Avoidance Modification Training for Subjective Stress in Adults: Pilot Randomized Controlled Trial

BACKGROUND

A key vulnerability factor in mental health problems is chronic stress. There is a need for easy-to-disseminate and effective interventions to advance the prevention of stress-related illnesses. App-based stress management trainings can fulfill this need. As subjectively experienced stress may be influenced by dysfunctional beliefs, modifying their evaluations might reduce subjective stress. Approach-avoidance modification trainings (AAMT) can be used to modify stimulus evaluations and are promising candidates for a mobile stress intervention. As the standard training reactions of the AAMT (swiping and joystick motion) have little valence, emotions could be incorporated as approach and avoidance reactions to enhance the effectiveness of AAMTs.

OBJECTIVE

We aimed to evaluate the feasibility of a mobile emotion-enhanced AAMT that engages users to display sadness to move stress-enhancing beliefs away and display positive emotions to move stress-reducing beliefs toward themselves (emotion-based AAMT using sadness and positive emotions [eAAMT-SP]). We explored the clinical efficacy of this novel intervention.

METHODS

We allocated 30 adult individuals with elevated stress randomly to 1 of 3 conditions (eAAMT-SP, a swipe control condition, and an inactive control condition). We evaluated the feasibility of the intervention (technical problems, adherence, usability, and acceptability). To explore the clinical efficacy of the intervention, we compared pretest-posttest differences in perceived stress (primary clinical outcome) and 3 secondary clinical outcomes (agreement with and perceived helpfulness of dysfunctional beliefs, emotion regulation, and depressive symptoms) among the conditions.

RESULTS

The predetermined benchmarks of 50% for intervention completion and 75% for feasibility of the study design (completion of the study design) were met, whereas the cutoff for technical feasibility of the study design (95% of trials without technical errors) was not met. Effect sizes for usability and acceptability were in favor of the eAAMT-SP condition (compared with the swipe control condition; intelligibility of the instructions: g=-0.86, distancing from dysfunctional beliefs: g=0.22, and approaching functional beliefs: g=0.55). Regarding clinical efficacy, the pretest-posttest effect sizes for changes in perceived stress were g=0.80 for the comparison between the eAAMT-SP and inactive control conditions and g=0.76 for the comparison between the eAAMT-SP and swipe control conditions. Effect sizes for the secondary clinical outcomes indicated greater pretest-posttest changes in the eAAMT-SP condition than in the inactive control condition and comparable changes in the swipe control condition.

CONCLUSIONS

The findings regarding the feasibility of the intervention were satisfactory except for the technical feasibility of the intervention, which should be improved. The effect sizes for the clinical outcomes provide preliminary evidence for the therapeutic potential of the intervention. The findings suggest that extending the AAMT paradigm through the use of emotions may increase its efficacy. Future research should evaluate the eAAMT-SP in sufficiently powered randomized controlled trials.

TRIAL REGISTRATION

German Clinical Trials Registry DRKS00023007; https://drks.de/search/en/trial/DRKS00023007.

Evaluating the feasibility and exploring the efficacy of an emotion-based approach-avoidance modification training (eAAMT) in the context of perceived stress in an adult sample - protocol of a parallel randomized controlled pilot study

BACKGROUND

Stress levels and thus the risk of developing related physical and mental health conditions are rising worldwide. Dysfunctional beliefs contribute to the development of stress. Potentially, such beliefs can be modified with approach-avoidance modification trainings (AAMT). As previous research indicates that effects of AAMTs are small, there is a need for innovative ways of increasing the efficacy of these interventions. For this purpose, we aim to evaluate the feasibility of the intervention and study design and explore the efficacy of an innovative emotion-based AAMT version (eAAMT) that uses the display of emotions to move stress-inducing beliefs away from and draw stress-reducing beliefs towards oneself.

METHODS

We will conduct a parallel randomized controlled pilot study at the Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany. Individuals with elevated stress levels will be randomized to one of eight study conditions (n = 10 per condition) - one of six variants of the eAAMT, an active control intervention (swipe-based AAMT), or an inactive control condition. Participants in the intervention groups will engage in four sessions of 20-30 min (e)AAMT training on consecutive days. Participants in the inactive control condition will complete the assessments via an online tool. Non-blinded assessments will be taken directly before and after the training and 1 week after training completion. The primary outcome will be perceived stress. Secondary outcomes will be dysfunctional beliefs, symptoms of depression, emotion regulation skills, and physiological stress measures. We will compute effect sizes and conduct mixed ANOVAs to explore differences in change in outcomes between the eAAMT and control conditions.

DISCUSSION

The study will provide valuable information to improve the intervention and study design. Moreover, if shown to be effective, the approach can be used as an automated smartphone-based intervention. Future research needs to identify target groups benefitting from this intervention utilized either as stand-alone treatment or an add-on intervention that is combined with other evidence-based treatments.

TRIAL REGISTRATION

The trial has been registered in the German Clinical Trials Register (Deutsches Register Klinischer Studien; DRKS00023007 ; September 7, 2020).

Augmenting outpatient alcohol treatment as usual with online approach bias modification training: A double-blind randomized controlled trial

Previous research shows that automatic tendency to approach alcohol plays a causal role in problematic alcohol use and can be retrained by Approach Bias Modification (ApBM). ApBM has been shown to be effective for patients diagnosed with alcohol use disorder (AUD) in inpatient treatment. This study aimed to investigate the effectiveness of adding an online ApBM to treatment as usual (TAU) in an outpatient setting compared to receiving TAU with an online placebo training. 139 AUD patients receiving face-to-face or online treatment as usual (TAU) participated in the study. The patients were randomized to an active or placebo version of 8 sessions of online ApBM over a 5-week period. The weekly consumed standard units of alcohol (primary outcome) was measured at pre-and post-training, 3 and 6 months follow-up. Approach tendency was measured pre-and-post ApBM training. No additional effect of ApBM was found on alcohol intake, nor other outcomes such as craving, depression, anxiety, or stress. A significant reduction of the alcohol approach bias was found. This research showed that approach bias retraining in AUD patients in an outpatient treatment setting reduces the tendency to approach alcohol, but this training effect does not translate into a significant difference in alcohol reduction between groups. Explanations for the lack of effects of ApBM on alcohol consumption are treatment goal and severity of AUD. Future ApBM research should target outpatients with an abstinence goal and offer alternative, more user-friendly modes of delivering ApBM training.

Approach-Bias Retraining and Other Training Interventions as Add-On in the Treatment of AUD Patients

In the past two decades, a variety of cognitive training interventions have been developed to help people overcome their addictive behaviors. Conceptually, it is important to distinguish between programs in which reactions to addiction-relevant cues are trained (varieties of cognitive bias modification, CBM) and programs in which general abilities are trained such as working memory or mindfulness. CBM was first developed to study the hypothesized causal role in mental disorders: by directly manipulating the bias, it was investigated to what extent this influenced disorder-relevant behavior. In these proof-of-principle studies, the bias was temporarily modified in volunteers, either temporarily increased or decreased, with corresponding effects on behavior (e.g., beer consumption), in case the bias was successfully manipulated. In subsequent clinical randomized controlled trials (RCTs), training (away from the substance vs. sham training) was added to clinical treatment. These studies have demonstrated that CBM, as added to treatment, reduces relapse with a small effect of about 10% (similar effect size as for medication, with the strongest evidence for approach-bias modification). This has not been found for general ability training (e.g., working memory training), although effects on other psychological functions have been found (e.g., impulsivity). Mindfulness also has been found to help people overcome addictions, and different from CBM, also as stand-alone intervention. Research on (neuro-)cognitive mechanisms underlying approach-bias modification has pointed to a new perspective in which automatic inferences rather than associations are influenced by training, which has led to the development of a new variety of training: ABC training.

Approach bias retraining to augment smoking cessation: A pilot randomized controlled trial

BACKGROUND

Approach tendency to smoking-related cues has been associated with greater cravings, nicotine dependence, and the likelihood of relapse. In this pilot randomized clinical trial, we examined the efficacy of approach bias retraining (ABR; i.e., increasing avoidance tendency) for enhancing standard smoking cessation treatment (ST).

METHODS

Adult smokers (N = 96) motivated to quit were randomly assigned to 7 weekly in-person treatment sessions consisting of either (1) cognitive-behavioral therapy for smoking cessation (ST) and ABR (ST+ABR) or ST and sham retraining (ST+Sham). All participants also received optional nicotine replacement therapy for up to 8 weeks following the scheduled quit date (week 6). We measured avoidance tendency from weeks 1-7. Point prevalence abstinence (PPA) and prolonged abstinence (PA) were measured up to 3 months following the quit attempt (week 18 follow-up).

RESULTS

Consistent with our hypothesis, participants in ST+ABR evidenced higher abstinence rates than those in ST+Sham at the final follow-up (b=0.71, 95 % CI: [0.14, 1.27], t[1721]=2.46, p = 0.014, OR=2.03, 95 % CI: [1.15, 3.57]). Specifically, PPA and PA rates were 50 % and 66 % in ST+ABR compared to 31 % and 47 % in ST+Sham. As expected, participants assigned to the ST+ABR condition also showed a greater training-compatible increase in avoidance tendency scores relative to those assigned to the ST+Sham condition (b=248.06, 95 % CI: [148.51, 347,62], t[84]=4.96, p < .001).

CONCLUSIONS

The current pilot randomized clinical trial provides initial evidence for the efficacy of integrating standard smoking cessation with ABR. These findings encourage the testing of the long-term efficacy and mechanisms of action of this integrated intervention.

Efficacy of approach bias modification as an add-on to smoking cessation treatment: study protocol for a randomized-controlled double-blind trial

Background

Although effective treatments for smoking cessation are available, long-term abstinence is the exception rather than the norm. Accordingly, there is a need for novel interventions that potentially improve clinical outcome. Although implicit information processing biases, for example approach biases for smoking-related stimuli, are ascribed a dominant role in the maintenance of tobacco dependence, these biases are hardly targeted in current treatment. Past research has shown that so-called Approach Bias Modification (AppBM) trainings, aiming to modify this bias, lead to improved long-term abstinence in abstinent alcoholic inpatients when delivered as an add-on to treatment-as-usual. Findings on the efficacy of AppBM in smoking have been inconsistent. The present large-scale clinical trial pursues two goals. First, it aims to investigate the efficacy of AppBM as an add-on to treatment-as-usual in a representative sample of adult smokers. Second, possible mechanisms of change are investigated.

Methods

The study is a randomized-controlled, double-blind, parallel-group superiority trial. We aim at a final sample of at least 336 adult smokers. Participants are allocated with a 1:1:1 allocation ratio to one of the following conditions: (1) treatment-as-usual + AppBM, (2) treatment-as-usual + Sham, (3) treatment-as-usual only. During the add-on training, participants are presented smoking-related and positive pictures and are instructed to respond by either pushing or pulling a joystick, depending on the tilt of the pictures (5^○ to the left/right). During AppBM, all smoking-related pictures are tilted in the direction that is associated with pushing, thereby aiming to train an avoidance bias for smoking. All positive pictures are tilted in the direction associated with pulling. During Sham, the contingency is 50/50. Participants are assessed before and after the intervention and at a 6-month follow-up. The primary outcome is prolonged abstinence, and secondary outcomes include smoking-related variables and psychological distress. Additionally, the motivational significance of smoking-related stimuli (i.e., approach bias, valence) is assessed with different experimental tasks (Approach-Avoidance Task; Single Target Implicit Association Test) and psychophysiological measures.

Discussion

This is the first large-scale clinical trial investigating the efficacy of AppBM as an add-on in smokers including a TAU only condition. Additionally, it is the first study to systematically investigate potential mechanisms mediating the effects of treatment on clinical outcome.

Trial registration

German Clinical Trials Register, DRKS00019221, 11/11/2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06155-6.

"Push it!" or "Hold it!"? A comparison of nicotine-avoidance training and nicotine-inhibition training in smokers motivated to quit

RATIONALE

Recently, experimental paradigms have been developed to strengthen automatic avoidance or inhibitory responses for smoking cues. However, these procedures have not yet been directly compared regarding their effectiveness and mechanisms of action.

OBJECTIVE

This study compared the effects of avoidance vs. inhibitory training as an add-on to a brief smoking cessation intervention. The standard Approach-Avoidance-Task (AAT) was adapted for both training types and control conditions.

METHODS

One hundred twenty-four smokers attended behavioral counseling for smoking cessation and were thereafter randomized to one of four training conditions: avoidance-AAT, sham-avoidance-AAT, inhibition-AAT, sham-inhibition-AAT. During a 2-week training period including five training sessions, smokers in the avoidance-AAT trained to implicitly avoid all smoking-related cues, while smokers in the inhibition-AAT trained to implicitly inhibit behavioral response to smoking cues. During sham training, no such contingencies appeared. Self-report and behavioral data were assessed before and after training. Cigarette smoking and nicotine dependence were also assessed at 4- and 12-week follow-ups.

RESULTS

At posttest, avoidance training was more effective in reducing daily smoking than inhibition training. However, this difference was no longer evident in follow-up assessments. All training conditions improved other smoking- and health-related outcomes. Neither training changed smoking-related approach biases or associations, but approach biases for smoking-unrelated pictures increased and Stroop interference decreased in all conditions. Smoking devaluation was also comparable in all groups.

CONCLUSIONS

Avoidance training might be slightly more effective in reducing smoking than inhibitory training. Overall, however, all four training types yielded equivalent therapy and training effects. Hence, a clear preference for one type of training remains premature.

A Pilot Study on Approach Bias Modification in Smoking Cessation: Activating Personalized Alternative Activities for Smoking in the Context of Increased Craving

Background

The act of smoking has been associated with the automatic activation of approach biases towards smoking-related stimuli. However, previous research has produced mixed findings when smokers are trained to avoid such smoking-related stimuli through the application of Approach Bias Modification (ApBM). As such, this study aimed to test an improved ApBM (ApBM +), where smokers were trained to approach personalized alternative activities for smoking in the context of increased craving, in addition to training smoking-avoidance responses.

Methods

Sixty-seven daily smokers motivated to quit (M age = 29.27, 58.2% female) were randomly assigned to seven sessions of either ApBM + (n = 26), standard-ApBM (n = 19), or sham-ApBM (n = 22), after a brief motivational smoking intervention. Primary outcomes of approach biases for smoking and for alternative activities and secondary outcomes of smoking-related behaviors were assessed at pre-test, post-test, and 1-month follow-up.

Results

Overall, no group differences by condition were demonstrated in changing approach biases or smoking-related behaviors at post-test and 1-month follow-up. A trend level indication for differences in changes of smoking-approach biases between sham-ApBM and ApBM + for relatively heavy smokers was found at post-test. This was primarily driven by a significant increase in smoking-approach biases within the sham-ApBM condition and a trend decrease in smoking-approach biases within the ApBM + condition.

Conclusions

Our findings did not provide support for the current ApBM + concerning improved effects across the whole sample. Diverging training effects on approach biases for smoking in relatively heavy smokers warrants further research, for which we provide some suggestions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12529-021-10033-x.

Effects of go/no-go training on food-related action tendencies, liking and choice

Inhibitory control training effects on behaviour (e.g. 'healthier' food choices) can be driven by changes in affective evaluations of trained stimuli, and theoretical models indicate that changes in action tendencies may be a complementary mechanism. In this preregistered study, we investigated the effects of food-specific go/no-go training on action tendencies, liking and impulsive choices in healthy participants. In the training task, energy-dense foods were assigned to one of three conditions: 100% inhibition (no-go), 0% inhibition (go) or 50% inhibition (control). Automatic action tendencies and liking were measured pre- and post-training for each condition. We found that training did not lead to changes in approach bias towards trained foods (go and no-go relative to control), but we warrant caution in interpreting this finding as there are important limitations to consider for the employed approach-avoidance task. There was only anecdotal evidence for an effect on food liking, but there was evidence for contingency learning during training, and participants were on average less likely to choose a no-go food compared to a control food after training. We discuss these findings from both a methodological and theoretical standpoint and propose that the mechanisms of action behind training effects be investigated further.

Comparison of different response devices to assess behavioral tendencies towards chocolate in the approach-avoidance task

Behavioral tendencies in the Approach-Avoidance Task (AAT) have mostly been assessed using a joystick as a response device. In recent years, other hardware devices such as tablets, smartphones, and computer mice have also been used. However, it remains unclear whether different response devices yield similar results and show comparable psychometric properties. The aim of the present study was to assess approach biases towards chocolate with different response devices and to compare their reliability and validity. Forty-five individuals with regular chocolate consumption completed three different AATs (joystick, computer mouse, touchscreen), each comprised of two blocks. In the compatible block of trials, chocolate-related pictures had to be pulled near while object-related pictures had to be pushed away. In the incompatible block of trials, instructions were reversed. Preregistered analyses revealed that participants were faster to pull than to push chocolate-related pictures relative to object-related pictures, indicating an approach bias for chocolate with no significant differences between response devices. Correlations among the three response devices were low to medium. Exploratory analyses revealed that approach biases were moderated by block order such that biases were only present and associated with craving (joystick AAT only) when the incongruent block was completed first. Internal consistencies of the bias score ranged between r_SB = 0.67-0.76. Results of the present study point to the existence of an approach bias to chocolate regardless of response device, albeit each task seems to measure a different aspect of it. Order effects point to specific temporal dynamics in the acquisition of stimulus response (e.g., chocolate-pull) mappings that require further study.

Approach bias retraining through virtual reality in smokers willing to quit smoking: A randomized-controlled study

Automatic approach biases toward smoking-related cues have been implicated in the development and maintenance of addictive behaviors. Studies aiming at modifying such biases have shown promise in changing maladaptive approach tendencies for smoking cues and reducing smoking behavior. However, training effects tend to be small and partly inconsistent. The present randomized-controlled trial incorporated virtual reality (VR) technology into Approach Bias Modification (ABM) to improve efficacy. One-hundred-eight smokers attended behavioral counseling for smoking cessation and were thereafter randomized to receive VR-ABM or VR-control training. During VR-ABM, participants trained to implicitly avoid smoking-related objects and to approach alternative objects, while no such contingency existed in the VR-control condition. Trainings were administered in six sessions within a two-week period. Assessments were conducted at baseline, post-intervention (three weeks after baseline), and at follow-up (seven weeks after baseline). VR-ABM did not change approach biases, nor other cognitive biases, but it was superior in reducing daily smoking. However, this effect was limited to the two-week training period. Both groups improved in other smoking- and health-related variables across time. Future work should continue to investigate working mechanisms of ABM, in particular crucial training ingredients. VR could prove valuable for public health as the potential of VR-based treatments is large and not fully explored.

ABC Training: A New Theory-Based Form of Cognitive-Bias Modification to Foster Automatization of Alternative Choices in the Treatment of Addiction and Related Disorders

Recent years have seen a surge in the popularity of interventions that target common distortions in thinking (cognitive-bias modification, or CBM). Although there is evidence of their effectiveness as add-ons to regular treatment in alcohol addiction, the effects are typically small, and recent findings from lab studies have called into question the dominant theoretical underpinnings of CBM. We provide a novel theoretical approach in terms of automatic inferences that integrates previous findings and suggests ways to improve CBM into ABC training. In ABC training, patients are trained in the context of personally relevant antecedents (A) to make behavioral choices (B) that accord with patients’ health goals in light of their consequences (C). We discuss preliminary evidence suggesting that ABC training might be a useful tool in the treatment of addictions and related disorders.

A randomized controlled trial of a virtual reality based, approach-avoidance training program for alcohol use disorder: a study protocol

BACKGROUND

The approach-avoidance training program (AATP) has shown preliminary promise as an add-on to standard treatment for alcohol dependence. However, knowledge is lacking as to whether the effectiveness of AATP can be enhanced further when performed in a typical drinking situation. The main aim of this study is to investigate whether approach-avoidance training implemented in a virtual reality bar environment is superior to the classical joystick PC-version of the AATP.

METHODS

The study will be implemented as a randomized controlled trial. A total of 204consecutively enrolled alcohol use disorder (AUD) patients, recruited from alcohol inpatient clinics in Germany, Poland and Denmark, will be randomized into one of three groups at the start of standard alcohol treatment: group A) stimuli-relevant AATP + treatment as usual (TAU); group B) stimuli-relevant AATP in virtual reality + TAU, and group C) TAU only (control group). Treatment outcomes will be assessed at pre-treatment, post-treatment and 3-month follow-up. Repeated-measures ANOVA will be applied to compare the trajectories of the groups over time on drinking, craving and impulsiveness outcomes. It is hypothesized that the two experimental groups will achieve better treatment outcomes compared to group C and that group B will achieve better outcomes than group A.

DISCUSSION

This study is the first trial examining the effectiveness of stimuli-relevant AATP delivered in a VR environment. The use of VR has shown promise in enhancing the effectiveness of other psychological treatments and since AATP has already been shown effective as add-on treatment, it is of interest to investigate whether these effects can be further enhanced by implementing the program in more ecologically valid environments. If proven effective, the AATP-VR can, like the AATP, be implemented easily and cheaply as add-on treatment or continued care to enhance the effectiveness of current evidence-based treatment.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04283305 Registration date: 24.02.20.

Combining Web-Based Attentional Bias Modification and Approach Bias Modification as a Self-Help Smoking Intervention for Adult Smokers Seeking Online Help: Double-Blind Randomized Controlled Trial

BACKGROUND

Automatically activated cognitive motivational processes such as the tendency to attend to or approach smoking-related stimuli (ie, attentional and approach bias) have been related to smoking behaviors. Therefore, these cognitive biases are thought to play a role in maintaining smoking behaviors. Cognitive biases can be modified with cognitive bias modification (CBM), which holds promise as an easy-access and low-cost online intervention. However, little is known about the effectiveness of online interventions combining two varieties of CBM. Targeting multiple cognitive biases may improve treatment outcomes because these biases have been shown to be relatively independent.

OBJECTIVE

This study aimed to test the individual and combined effects of two web-based CBM varieties-attentional bias modification (AtBM) and approach bias modification (ApBM)-in a double-blind randomized controlled trial (RCT) with a 2 (AtBM: active versus sham) × 2 (ApBM: active versus sham) factorial design.

METHODS

A total of 504 adult smokers seeking online help to quit smoking were randomly assigned to 1 of 4 experimental conditions to receive 11 fully automated CBM training sessions. To increase participants' intrinsic motivation to change their smoking behaviors, all participants first received brief, automated, tailored feedback. The primary outcome was point prevalence abstinence during the study period. Secondary outcomes included daily cigarette use and attentional and approach bias. All outcomes were repeatedly self-assessed online from baseline to the 3-month follow-up. For the examination of training effects on outcome changes, an intention-to-treat analysis with a multilevel modeling (MLM) approach was adopted.

RESULTS

Only 10.7% (54/504) of the participants completed all 11 training sessions, and 8.3% (42/504) of the participants reached the 3-month follow-up assessment. MLM showed that over time, neither AtBM or ApBM nor a combination of both differed from their respective sham training in point prevalence abstinence rates (P=.17, P=.56, and P=.14, respectively), and in changes in daily cigarette use (P=.26, P=.08, and P=.13, respectively), attentional bias (P=.07, P=.81, and P=.15, respectively), and approach bias (P=.57, P=.22, and P=.40, respectively), while daily cigarette use decreased over time across conditions for all participants (P<.001).

CONCLUSIONS

This RCT provides no support for the effectiveness of combining AtBM and ApBM in a self-help web-based smoking cessation intervention. However, this study had a very high dropout rate and a very low frequency of training usage, indicating an overall low acceptability of the intervention, which precludes any definite conclusion on its efficacy. We discuss how this study can inform future designs and settings of online CBM interventions.

TRIAL REGISTRATION

Netherlands Trial Register NTR4678; https://www.trialregister.nl/trial/4678.

Imaginal Retraining Reduces Cigarette Smoking: A Randomized Controlled Study

OBJECTIVES

Smoking is a highly prevalent addictive behavior with severe and life-shortening health consequences. This is the first study to evaluate the efficacy of a newly developed imaginal variant of approach bias modification (ABM) (i.e., imaginal retraining) for the reduction of craving for tobacco and actual smoking behavior.

METHODS

We randomized 345 smokers to imaginal retraining (self-help manual) or a control group (either active control or wait-list control). Assessments were carried out online. The treatment interval was 6 weeks. Craving for tobacco represented the primary outcome. The study was registered as DRKS00016860.

RESULTS

Retention was 79.7% with no difference between groups. The intention-to-treat (ITT) analyses were significant for the primary outcome (Visual Analogue Scale on craving for tobacco) as well as subjective reduction of smoking (45.5 vs. 26.4%) in favor of imaginal retraining. In the treatment group, 47.6% performed the exercises at least once. This subgroup (per-protocol [PP] sample) showed a significant reduction in tobacco dependency as measured with the Cigarette Dependence Scale (short and long forms) and the Fagerström Test for Nicotine Dependence relative to controls. Number of daily cigarettes declined to a greater extent in imaginal retraining in the PP but not ITT analysis. A small dose-effect relationship emerged between craving and frequency of performance of the technique.

CONCLUSION

When used regularly, imaginal retraining may reduce craving for tobacco and actual smoking behavior in a subgroup of smokers. In view of the large subgroup that did not read the manual or did not perform the exercises, alternative ways of conveying the imaginal retraining technique should be sought (e.g., demonstration via video clips). To conclude, imaginal retraining may represent a simple low-threshold technique to reduce smoking and assist current evidence-based treatment programs targeted at abstinence. It needs to be tested whether its mechanism of action deviates from standard ABM.