Approach Bias Retraining for Nicotine Addiction among Dual Combustible and Electronic Cigarette Users

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ABSTRACT Electronic cigarette (ECIG) use has become a popular method for nicotine delivery. Combustible cigarette (CC) cessation or reduction are the primary reasons for ECIG uptake among adults.1-3 Yet, most CC smokers who initiate ECIG use do not fully transition from CC to ECIG, despite intending to quit CC completely.4-9 Longitudinal work has found that 89% of dual users—users of ECIG and CC concurrently--remain dual users a year after initial assessment.10 Continued dual use is alarming because it is associated with increased nicotine use and dependence.11 Consequently, dual users are exposed to CC toxins and constituents, including carcinogens, at levels comparable to exclusive CC smokers.12 Theory and empirical findings suggest that targeting automated, impulsive, implicit processes may hold promise for substance use reduction and cessation.13-18 Specifically, retraining approach bias, or the approach action tendency toward stimuli related to the substance of interest, has been effective in alcohol use disorders (i.e., reduction in relapse rates by 10%-13%).18-20 When applied to CC- related stimuli, approach bias retraining has been found to reduce approach bias, which is subsequently related to greater number of days abstinent from CC following a self-guided quit attempt.21 This R21 application will evaluate the initial efficacy of approach bias retraining among dual CC/ECIG users. To obtain initial effect size data for a larger R01 follow-up study, we will randomly assign 90 dual CC/ECIG using adults to one of three conditions: (1) CC+ECIG retraining; (2) CC only retraining; and (3) sham training (control). Participants will complete 4 sessions of approach bias retraining using the respective stimuli and then engage in a self-guided quit attempt to abstain from all nicotine products. Each session will consist of 15 minutes of computerized approach bias retraining and a brief assessment. Participants will provide baseline data, ecological momentary assessment (EMA) data during the first two weeks post-intervention, and complete follow-ups at 4- and 6-week post-intervention. Abstinence will be assessed during the intervention (weeks 0-4), during the EMA period, and at both follow-ups. The proposed study represents a crucial and important ‘next step’ in translating basic research to strategies for treating nicotine dependence among dual CC/ECIG users. The investigation addresses an important public health issue by testing a brief computerized intervention - informed by basic research - that may lead to a more effective treatment for at-risk nicotine users while simultaneously isolating explanatory mechanisms. The expected findings should: (1) guide advances in the theoretical conceptualization of nicotine addiction for dual users and mechanisms involved in maintaining and abstaining from CC and ECIG; and (2) provide initial effect size data for a brief intervention, and thus provide the necessary data for a large-scale follow-up trial.