JMIR Publications

ABSTRACT

Background:

Automatically activated cognitive motivational processes such as the tendency to attend to or approach smoking-related stimuli (i.e., 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 internet 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:

The aim of this study was 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 one of four experimental conditions to receive 11 fully-automated CBM training sessions. To increase participants’ intrinsic motivation to change their smoking behaviors, all participants first received a brief automatized tailored feedback. Primary outcome was point prevalence abstinence along 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. An Intention-To-Treat (ITT) analysis with a Multilevel Modeling (MLM) approach was adopted to examine training effects on outcome changes.

Results:

Among the participants, only 10.7% (54/504) completed all 11 training sessions and 7.9% (42/504) reached the 3-month follow-up assessment. MLM showed that over time, CBM training conditions did not differ in point prevalence abstinence rates (all P ≥ .14), and in changes in daily cigarette use (all P ≥ .08) and cognitive biases (all P ≥ .07), while daily cigarette use decreased over time across conditions for all participants (all P < .001).

Conclusions:

This RCT provides no support for the effectiveness of combining AtBM and ApBM in a self-help online smoking cessation intervention. However, this study has a very high drop-out rate and a very low frequency of training usage, indicating a general low acceptability of the intervention, which precludes any definite conclusion on its effectiveness. We discuss how this current study can inform future designs and settings of online CBM interventions. Clinical Trial: Netherlands Trial Register NTR4678; https://www.trialregister.nl/trial/4678 (Archived by WebCite at http://www.webcitation.org/77WyWLhgj)