The role of attentional bias, counterfactual thinking, and protective behavioral strategies in ENDS users

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PROJECT SUMMARY/ABSTRACT The use of electronic nicotine delivery systems (ENDS) is on the rise and has been linked to nicotine dependence. Abuse of ENDS is associated with a variety of adverse consequences, but as is frequently observed with substance dependence, these adverse consequences are often insufficient to motivate and sustain quitting attempts. Nicotine dependence remains a significant public health burden. New approaches to facilitate quitting and sustain abstinence are needed, which will require novel insights into why a nicotine addiction remains so difficult to overcome. Attention has long been understood to play an important role in the addiction process, including nicotine addiction. Attention selects which aspects of sensory input receive cognitive processing and thereby influence behavior. A substantial body of research has been devoted to investigating the mechanisms by which smoking-related cues draw attention through reward-mediated processes and the degree to which these biases predict quitting, along with developing attentional bias modification techniques intended to facilitate quitting. These efforts have been largely unsuccessful and therefore appear to fall short of accounting for the full range of information processing biases responsible for the maintenance of a nicotine addiction. In the pursuit of a more comprehensive account of these biases, the influence of aversive outcomes on attention offers promise. Interest in how aversive outcomes influence the control of attention has grown in recent years, and robust biases towards aversively conditioned stimuli have been identified in non-clinical samples. The role of aversive conditioning in attention could be especially pertinent to understanding why individuals often maintain an addiction despite repeated exposure to its harmful effects, which could reflect under-prioritization of threat cues that then fail to deter addictive behaviors. Research suggests that cognitive avoidance strategies may improve attentional control when the individual is given ample time to apply the strategy. Cognitive strategies, such as counterfactual thinking paired with clinically backed strategies (i.e., protective behavioral strategies; PBS), may serve as the steppingstone towards more adaptive attentional bias towards threat stimuli. However, how attention is influenced by counterfactuals paired with PBS remains unexplored. To address this gap, the proposed research seeks to identify how ENDS users and non-users differ with respect to attentional bias and CF processes. New Specific Aim 1 focuses on the relationship between attentional bias and CF content, providing an initial glimpse into how individuals with nicotine addiction engage in CF processes. New Specific Aims 2 extends this by focusing on how CFs and attentional bias predict PBS engagement, intentions, and ENDS use measures. The findings will provide necessary insights into the role of cognitive processes, such as CFs and attentional bias, in the realm of nicotine addiction, the implications of which can help inform many of the cognitive-behavioral techniques used in clinical assessments and intervention programs.