Smoking Cessation Clinical Trial
Official title:
Mechanisms Underlying the Approach and Avoidance Task (AAT) in Smoking Cessation
The approach and avoidance task (AAT) has evolved as a promising treatment add-on in the
realm of psychology. Certain psychiatric diseases, such as behavioural addictions, social
anxiety disorder, and arachnophobia, are characterized by a dysfunctional tendency to either
approach or avoid disease-specific objects. This tendency can be measured by means of the
approach and avoidance task. More precisely, by a diagnostic AAT, in which participants are
instructed to react upon the format or the frame colour of a picture. For instance, pictures
have to be pushed away if they are presented in landscape format and pulled towards oneself
if they are presented in portrait format (or vice versa). Hence, the format (or the frame
colour) becomes the task-relevant dimension, whereas the content of the picture becomes
irrelevant for task completion. However, what generally becomes obvious in the psychiatric
diseases mentioned above is that the task-irrelevant dimension (picture content) exerts an
influence on reaction times. For instance, smokers are generally faster to respond to
smoking-related pictures, when presented in a format requiring them to pull towards
themselves, and slower to respond, if smoking pictures are shown in the format requiring them
to push away a joystick (Wiers et al., 2013). This behavioural tendency has been termed an
approach bias for cigarettes or smoking.
In order to counteract these dysfunctional approach or avoidance tendencies, an AAT-training
has been developed. In this training participants/patients learn to either avoid or approach
disease-specific objects. Smokers, for instance, learn to avoid smoking-related pictures by
pushing or swiping the image away. It has been shown that these trainings can lower cigarette
consumption among current smokers (Machulska, Zlomuzica, Rinck, Assian, & Margraf, 2016). The
aim of the current study is to test whether the avoidance gesture is as important as
suggested by the AAT's name or whether inhibiting the urge to approach smoking-related
content might be enough to bring about the effect. Furthermore, possible changes in general
and domain-specific (i.e. smoking-related) inhibition capacity, that might mediate the
effect, will be assessed. Another focus of study will be on functional as well as structural
neuronal changes, emerging as a consequence of the AAT-training.
The approach and avoidance task (AAT) has turned out as both a promising diagnostic tool as
well as treatment add-on in psychological science. The AAT constitutes one form of cognitive
bias modification (CBM), which has been shown to be particularly effective in the field of
behavioural addictions (Eberl et al., 2013; Wiers, Eberl, Rinck, Becker, & Lindenmeyer,
2011). The general logic underlying the AAT is to carry out actions that are either
compatible or incompatible with an individual's action tendencies. For instance, nicotine
addicted individuals tend to approach tobacco-related stimuli faster than control pictures,
when they are instructed to react upon the format of a picture and not to its' content. This
tendency of comparatively faster approaching and slower avoiding tobacco-related content has
been termed an approach bias nicotine/tobacco. The AAT as a therapeutic tool tries to
counteract or at least to attenuate approach or avoidance biases by instructing patients to
carry out approach or avoidance gestures that are in conflict with an individual's acquired
action tendencies.
Whereas the general effectiveness of the AAT as a clinical intervention has been demonstrated
several times, little is known about possible mechanisms that might subserve these effects.
Therefore, the current study is dedicated to shed some light on one such potential mechanism,
i.e. the role of the avoidance gesture within the alcohol-AAT.
As already suggested by the name of the AAT, the avoidance gesture seems to be a key
ingredient in bringing about therapeutic effects. However, recent empirical evidence has
brought about some interesting findings, giving rise to an alternative explanation.
A study by Kühn et al. (2017), contrary to common-held beliefs, indicated that inhibition
capacity can be trained. Inhibition, in turn, consistently has been linked to psychopathology
and all kinds of behavioural addictions (Smith, Mattick, Jamadar, & Iredale, 2014). The game
by Kühn et al. (2017), used to train inhibition, resembled the AAT in several ways, e.g.
certain stimuli appearing on a treadmill had to be collected by swiping towards oneself and
others had to be ignored and the objects slowly disappeared. The latter element contrasts
with the AAT, since the ignored objects don't have to be pushed away. However, it resembles
the AAT in the sense that in both cases stimuli slowly fade out of the screen and eventually
disappear. These parallel let to the assumption that a new form of the alcohol AAT training
might be equally effective in lowering relapse rates among alcoholic patients. More
precisely, within the newly conceptualized AAT training, patients are instructed to inhibit
the urge to respond in response to alcohol-related content and to observe the stimuli fading
out of the screen. In contrast to the classical AAT training, this zooming out of alcoholic
stimuli is not conditional on the avoidance gesture, i.e. swiping/pushing away the stimulus.
It is hypothesized that compared to a control group, in which tobacco and control stimuli
have to be swiped to the left and right, both the classical AAT-and the inhibition group will
be more successful in stopping or reducing smoking. The intervention includes a training
period of four weeks. No intergroup differences in terms of smoking cessation and
tobacco-related approach bias are expected for the classical AAT group and the inhibition
group after the intervention.
Furthermore, it will be explored whether inhibition capacity changes as a result of the
intervention, the assumption being that inhibition capacity increases for both experimental
groups, whereas no changes are expected for the control group. An interesting question
concerns the domain-specificity of potential effects. In other words, does inhibition
capacity improve only for the to be trained domain (i.e. tobacco) or does the general
inhibition capacity improve, irrespective of the to be trained domain? Predictions on this
issue are not straightforward, but it is assumed that both the general and domain-specific
inhibition capacity improve for the experimental groups, when compared to the control group.
Slightly more pronounced effects are expected for the domain-specific task, since the
training calls for comparable skills.
Hypotheses concerning experimental changes in brain structure are hard to make, as, to the
best of our knowledge, no research has been done on this topic up until now. Therefore,
whole-brain analyses will be run on all voxels of the brain in order to explore any
experimental changes both on the within and between subject level.
The same goes for functional changes in a Stop Signal Task (SST) and a cue reactivity
paradigm. It will be explored whether the classical AAT group and the inhibition group show
less reward-related activity in response to addiction-related stimuli than participants in
the control group. Furthermore, it will be explored whether brain regions commonly associated
with inhibition capacity show more activity in response to smoking-related stimuli, since
this has been learned throughout the training period.
All secondary outcome measures (e.g. smoking-related questionnaires, Beck's Depression
Inventory, Barratt's Impulsivity Scale, AUDIT) assess whether the experimental manipulations
lead to a reduction in psychopathological symptoms. Therefore, both experimental groups are
expected to show post-interventional declines in nicotine-dependence measures and other
measures associated with dependence, such as mental well-being and impulsivity. In contrast,
no changes across time are expected for the control group.
In order to test prior mentioned hypotheses, a randomized controlled trial will be conducted.
Each of the three groups (inhibition group, classical AAT group, and control group) will
consist out of 25 mentally healthy participants, who just stopped smoking or just start an
attempt to quit smoking.
In total the study consists out of three points of measurement. After the baseline testing,
which assesses participants' approach bias for tobacco, their tobacco history, tobacco
consumption within the last months, a multitude of smoking-related questionnaires (see
secondary outcome measures), the two inhibition tasks, brain structure and brain function,
participants are provided with a tablet on which the AAT app is installed. The participants
are asked to train with the app for at least 15 minutes daily within a four-week period.
Following this training, the second point of measurement will take place. The general
procedure is identical to the first point of measurement. Another four weeks later, the third
point of measurement marks the end of the study. Once again, the measures are the same except
for the fact that no MRI scan is realized on this last occasion, since the study is primarily
interested in post-interventional brain changes.
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