J. Behav. Ther. & Exp. Psychiat.

46 (2015) 115e120

Contents lists available at ScienceDirect

Journal of Behavior Therapy and

Experimental Psychiatry
journal homepage: www.elsevier.com/locate/jbtep

The approach-avoidance task as an online intervention in cigarette

smoking: A pilot study
Charlotte E. Wittekind a, *, Ansgar Feist a, Brooke C. Schneider a, Steffen Moritz a,
Anja Fritzsche b
a
University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistraße 52, 20246 Hamburg, Germany
b
University Hamburg, Department of Psychology and Psychotherapy, Von-Melle-Park 5, 20246 Hamburg, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Background and objectives: Dual-process models posit that addictive behaviors are characterized by
Received 18 March 2014 strong automatic processes that can be assessed with implicit measures. The present study investigated
Received in revised form the potential of a cognitive bias modification paradigm, the Approach-Avoidance Task (AAT), for
27 August 2014
retraining automatic behavioral tendencies in cigarette smoking.
Accepted 28 August 2014
Available online 16 September 2014
Methods: The study was set up as an online intervention. After completing an online survey, 257 smokers
were randomly allocated either to one of two experimental conditions (AAT) or a waitlist control group.
Participants responded to different pictures by pushing or pulling the computer mouse, depending on
Keywords:
Approach-avoidance task
the format of the picture. Pictures in portrait format depicted smoking-related items and were associated
Cognitive bias modification with pushing, pictures in landscape format depicted neutral items and were associated with pulling. One
Retraining version of the AAT provided individual feedback after each trial whereas the standard version did not.
Smoking After four weeks, participants were re-assessed in an online survey.
Cessation Results: Analyses revealed that the standard AAT, in particular, led to a significant reduction in cigarette
consumption, cigarette dependence, and compulsive drive; no effect was found in the control group.
Limitations: Interpretability of the study is constrained by the fact that no active control condition was
applied.
Conclusions: Notwithstanding the limitations, our findings indicate that the AAT might be a feasible
instrument to reduce tobacco dependence and can be applied as an online intervention. Future studies
should investigate whether the effects of behavior therapy can be augmented when combined with
retraining interventions.

© 2014 Elsevier Ltd. All rights reserved.

1. Introduction was shown that compared to non-dependent individuals, drug-

1.1. Information processing and approach-avoidance tendencies in
addiction
Despite being well aware of its negative consequences,
continued substance use is typical of addictive behaviors in
smokers (Wiers & Stacy, 2006). This discrepancy can be reconciled
by dual-process models of addiction, which posit that in addictive
disorders, there is an imbalance between automatic and reflective
systems in favor of automatic processes (Stacy & Wiers, 2010). It
* Corresponding author. Tel.: þ49 40 7410 53522; fax: þ49 40 7410 57566.
E-mail address: c.wittekind@uke.uni-hamburg.de (C.E. Wittekind).
dependent persons evaluate drug-related stimuli as more posi-
tive, followed by behavioral approach tendencies (Stacy & Wiers,
2010). For example, behavioral approach tendencies were found
in alcohol dependence (e.g., Wiers, Rinck, Dictus, & van den
Wildenberg, 2009) using an Approach-Avoidance Task (AAT,
Rinck & Becker, 2007). The AAT is based on the well-established
finding that positive stimuli activate approach tendencies,
whereas negative stimuli cause avoidance tendencies (e.g.,
Neumann, Fo €rster, & Strack, 2003). The AAT measures duration of
arm movements, with avoidance being characterized by reduced
response time of arm extending (pushing), and approach by
reduced response time of arm bending (pulling; Marsh, Kleck, &
Ambady, 2005).
AAT tendencies have been examined among patients who abuse
various substances (e.g., Cousijn, Goudriaan, & Wiers, 2011; Wiers

http://dx.doi.org/10.1016/j.jbtep.2014.08.006
0005-7916/© 2014 Elsevier Ltd. All rights reserved.
116 C.E. Wittekind et al. / J. Behav. Ther. & Exp. Psychiat. 46 (2015) 115e120
et al., 2009). Importantly, the AAT provided evidence that smoking
is associated with an approach bias toward smoking-related stimuli
(Watson, de Wit, Cousijn, Hommel, & Wiers, 2013; Wiers et al.,
2013).
1.2. The AAT as an interventional technique
The bidirectional link between direction of physical movements
and evaluation processes has also been employed to modify atti-
tudes, for example, in therapeutic contexts. Recent studies demon-
strated that automatic action tendencies to approach alcohol could
be retrained using a training variant of an alcohol AAT in hazardous
drinkers and alcoholic inpatients (Wiers, Eberl, Rinck, Becker, &
Lindenmeyer, 2011; Wiers, Rinck, Kordts, Houben, & Strack, 2010).
Furthermore, relapse rates were reduced in the AAT compared to the
control group after one year (Eberl et al., 2013; Wiers et al., 2011).
1.3. The present study
We adopted the AAT paradigm to smoking by presenting
smoking-related and neutral pictures. Participants were allocated
to one of two slightly different versions of the smoking-related AAT
or a waitlist control group. In both versions, participants were
instructed to respond to the format of pictures which corresponded
to smoking-related (portrait) or neutral items (landscape), by
pushing or pulling a joystick independent of the content of the
pictures. In the modified version, participants were shown their
reaction time (RT) after each trial. We decided to include the second
version because we wanted to examine whether immediate feed-
back would increase the effectiveness of the program by activating
achievement motives (Sokolowski, Schmalt, Langens, & Puca,
2000), thereby enhancing training compliance.
Although almost half of all smokers make an attempt to quit
(Shiffman, Brockwell, Pillitteri, & Gitchell, 2008), utilization of
behavioral treatment is very low (Cokkinides, Ward, Jemal, & Thun,
2005; Shiffman et al., 2008). Frequent reasons for low treatment
utilization are fear of stigma, unsuccessful efforts to find adequate
treatment, time constraints and the fact that smoking is not
considered a psychological problem but rather a bad habit. We
therefore carried out our study via the Internet which offers the
possibility to reach people that would otherwise be reluctant to
attend intervention programs (for a discussion of (dis-)advantages
see Gosling, Vazire, Srivastava, & John, 2004; Moritz, Timpano,
Wittekind, & Knaevelsrud, 2013). For the main outcome (ciga-
rettes/day), we hypothesized that both versions of the AAT training
will lead to a significant decrease in participants' daily cigarette
Excluded (n = 14)
Not meeting inclusion criteria (n = 2)
Not answering questions honestly (n = 2)
Entering invalid email address (n = 7)
Withdrawal of informed consent (n = 2)
Randomization error (n = 1)
Pre-assessment Randomized
(N = 271) (n = 257)
Fig. 1. CONSORT diagram.
consumption in comparison to the control group. Based on the
argumentation of the preceding paragraph, it is conceivable that
the modified AAT outperforms the standard AAT.
2. Material and methods
2.1. Recruitment
The study was set up as an online intervention using questback®
(www.unipark.com/de). Invitations and a short description of the
study were posted in several smoking-related internet forums. The
rationale and the procedure of the study were explained to par-
ticipants in written form both on the internet forums and on the
introduction page of the survey. We refrained from using an
approach tobacco condition as it is conceivable that this condition
would increase cigarette consumption. The survey consisted of the
following sections: introduction, informed consent, sociodemo-
graphic information, smoking behavior, psychiatric disorders, and
current medication. Subsequently, different questionnaires were
applied (see Section 2.7). Finally, participants were asked to provide
an email address.
2.2. Participants
The enrollment phase was terminated after 271 subjects had
completed the baseline survey. In total, 14 participants had to be
excluded from analyses (see Fig. 1). Participants were excluded if
they did not smoke within the last month or did not answer the
survey honestly. No other exclusion criteria were applied.
2.3. Intervention
Based on the principle of the AAT (Rinck & Becker, 2007), the
intervention was programmed using Visual Basic2010 Express
(Microsoft©) by AF. In total, 10 smoking-related and 10 neutral
pictures were presented. Pictures were matched regarding the
number of depicted items. After pressing a “start”-button, partici-
pants were asked to indicate their current urge to smoke. For the
training, smoking-related and neutral pictures were presented
randomly. Smoking-related pictures were presented in portrait
format and associated with “push”, neutral pictures were presented
in landscape format and associated with “pull”. After pressing the
start-button, a fixation cross appeared (500 ms) in the center of the
screen, followed by either a neutral or a smoking-related picture.
Pulling led to an enlarged picture while pushing lead to a reduced
picture. Moving the computer mouse in the right direction led to
Allocated to
standard AAT
(n = 87)
Allocated to Post-assessment
modified AAT (n = 156)
(n = 85)
Allocated to
waitlist control
group (n = 85)
 C.E. Wittekind et al. / J. Behav. Ther. & Exp. Psychiat. 46 (2015) 115e120 117

Table 1
Demographic and smoking-related information at baseline. Frequencies, means and standard deviations (in brackets).

Variable Standard AAT (n ¼ 87) Modified AAT (n ¼ 85) Control group (n ¼ 85) Statistics (df ¼ 254)

Age (in years) 44.30 (9.62) 43.65 (11.63) 41.55 (11.73) F ¼ 1.45, p ¼ .24
Education (in years) 11.95 (1.58) 11.80 (1.68) 11.85 (1.77) F < 1, p ¼ .83
Gender (female/male) 54/33 56/29 47/38 c2(2) ¼ 2.06, p ¼ .36
Cigarettes per day 20.31 (9.00) 20.13 (10.86) 20.52 (9.97) F < 1, p ¼ .97
Tobacco dependenceb 5.05 (2.50) 4.80 (2.41) 4.76 (2.55) F < 1, p ¼ .72
Smoking duration (in years) 24.27 (10.34) 25.09 (10.75) 22.62 (11.94) F ¼ 1.11, p ¼ .33a
Completion rate (in %) 63.2 54.1 64.7 c2(2) ¼ 2.35, p ¼ .31
Note. AAT ¼ Approach-Avoidance Task; df ¼ degree of freedom.
a
df ¼ 253.
b
Total score of the Fagerstrøm Test for Nicotine Dependence (0e2 ¼ very low, 3e4 ¼ low; 5 ¼ medium, 6e7 ¼ severe, 8e10 ¼ very severe).

the disappearance of the picture. Errors (i.e., moving mouse in
wrong direction) had to be corrected. By pressing the start-button,
the next trial was initiated. Each participant performed 100 trials.
Subsequently, participants were again asked to indicate their urge
to smoke. Finally, participants were provided with brief feedback.
Apart from the “traditional” AAT, we set up a modified AAT. Here,
upon disappearance of the picture, RT for each trial was shown (see
Section 1).
the intervention. If the intervention was used, several questions
pertaining to the program and other cessation strategies were
assessed (see Table 4). After indicating whether all questions had
been answered honestly, participants were thanked for their
participation and links were provided to download both AAT par-
adigms and a manual about progressive muscle relaxation.
2.6. Questionnaires

2.4. Group allocation
Participants who completed the baseline survey were randomly
allocated to one of three conditions (standard AAT [sAAT], modified
AAT [mAAT], waitlist control group) in pseudo-random order.
Experimental groups were sent an email with an instruction
manual attached. The control group was sent an email explaining
that participants would receive the program after the post-
assessment. Participants were informed that they could contact
the first author for questions.
2.5. Post-assessment
Four weeks after the baseline assessment, participants were
sent an email inviting them to participate in the post-assessment.
The first page contained a short introduction explaining the
importance of participation. Subsequently, participants were asked
to enter the same email address as in the baseline assessment in
order to match pre- and post-assessment data. The following in-
formation was assessed: current alcohol consumption, information
about smoking behavior, current medication, questionnaires from
the baseline assessment. Cigarette consumption was assessed with
item #2 of the Cigarette Dependence Scale (i.e., cigarettes per day).
Participants in the intervention groups were asked if they had used
Participants were asked to complete the following question-
naires at both pre- and post-assessment.
2.6.1. Commitment to Quitting Smoking Scale (CQSS)
The CQSS is an 8-item self-report instrument designed to
measure the commitment to quit smoking (internal consistency:
a ¼ .91). Studies suggest that greater commitment at baseline is
associated with a higher abstinence rate at follow-up (Kahler et al.,
2007).
2.6.2. Fagerstrøm Test for Nicotine Dependence (FTND)
The 6-item FTND (Heatherton, Kozlowski, Frecker, &
Fagerstrøm, 1991) is the most frequently used measure to tap to-
bacco dependence (Piper, McCarthy, & Baker, 2006) and has been
shown to be a reliable instrument (internal consistencies range
from a ¼ .55 to a ¼ .74; de Meneses-Gaya, Zuardi, Loureiro, & de
Souza Crippa, 2009).
2.6.3. Cigarette Dependence Scale-12 (CDS-12)
The 12-item CDS (Etter, Le Houezec, & Perneger, 2003) is a self-
report measure assessing addiction to cigarettes following the
diagnostic criteria of the DSM-IV and the ICD-10. The questionnaire
shows excellent reliability (internal consistency: a ¼ .90, test-retest
reliability for full scale: r ¼ .84; Etter et al., 2003).

Table 2
Group comparisons and results of the ANCOVAs for the outcome measures for pre, post, and across time, per protocol analyses.

Variable/time Pre per protocol Per protocol Post per protocol Per protocol between-group
between-group difference pre-post, ANCOVA
Waitlist Modified Standard Waitlist Modified Standard
difference pre
(n ¼ 55) AAT AAT (n ¼ 55) AAT AAT
(df ¼ 123)
(n ¼ 33) (n ¼ 38) (n ¼ 33) (n ¼ 38)

Cigarettes per day (n) 20.76 (9.95) 19.48 (7.13) 19.97 (8.93) F < 1, p ¼ .80 20.20 (10.55) 17.91 (7.35) 16.97 (10.07) F(2, 122) ¼ 3.55, p ¼ .032; h2p ¼ .06
FTND 4.55 (2.52) 4.67 (2.29) 4.89 (2.45) F < 1, p ¼ .79 4.47 (2.50) 4.42 (2.17) 4.08 (2.67) F(2, 122) ¼ 2.96, p ¼ .056, h2p ¼ .05
CQSS 26.96 (6.69) 25.27 (5.95) 25.97 (6.55) F < 1, p ¼ .48 27.62 (7.90) 24.15 (6.16) 25.03 (6.48) F(2, 122) ¼ 2.18, p ¼ .12, h2p ¼ .04
CDS-12 45.25 (9.17) 46.09 (5.81) 47.05 (8.31) F < 1, p ¼ .58 44.73 (9.97) 45.03 (5.49) 42.92 (9.92) F(2, 122) ¼ 5.62, p ¼ .005, h2p ¼ .08
OCSS total 15.98 (6.97) 18.94 (5.89) 19.05 (6.28) F ¼ 3.34, p ¼ .039 15.85 (6.77) 17.67 (4.84) 16.45 (7.31) F(2,122) ¼ 1.73, p ¼ .18, h2p ¼ .03
OCSS e preoccupation 8.31 (4.97) 10.30 (4.35) 10.24 (4.74) F ¼ 2.64, p ¼ .076 8.20 (4.67) 10.00 (3.74) 8.97 (4.96) F(2, 122) < 1, p ¼ .41, h2p ¼ .01
OCSS e Compulsive 7.67 (2.69) 8.64 (2.03) 8.82 (1.93) F ¼ 3.30, p ¼ .04 7.65 (2.74) 7.67 (1.67) 7.47 (2.81) F(2, 122) ¼ 3.32, p ¼ .039, h2p ¼ .05
drive

Note. df ¼ degree of freedom; AAT ¼ Approach-Avoidance Task; FTND ¼ Fagerstrøm Test for Nicotine Dependence (0e2 ¼ very low, 3e4 ¼ low; 5 ¼ medium, 6e7 ¼ severe,
8e10 ¼ very severe); CQSS ¼ Commitment to Quitting Smoking Scale; CDS-12 ¼ Cigarette Dependence Scale-12 (12 ¼ low dependence up to 60 ¼ high dependence);
OCSS ¼ Obsessive Compulsive Smoking Scale.
118 C.E. Wittekind et al. / J. Behav. Ther. & Exp. Psychiat. 46 (2015) 115e120

Table 3
Group comparisons and results of the ANCOVAs for the outcome measures for pre, post, and across time, last observation carried forward.

Variable/time Pre LOCF LOCF between-group Post LOCF LOCF between-group difference
difference pre pre-post, ANCOVA
Waitlist Modified Standard Waitlist Modified Standard
(df ¼ 254)
(n ¼ 85) AAT AAT (n ¼ 85) AAT AAT
(n ¼ 85) (n ¼ 87) (n ¼ 85) (n ¼ 87)

Cigarettes per day (n) 20.52 (9.97) 20.13 (10.86) 20.31 (9.00) F < 1, p ¼ .97 20.09 (10.40) 19.38 (10.95) 18.46 (9.84) F(2, 253) ¼ 3.85, p ¼ .023; h2p ¼ .03
FTND 4.76 (2.55) 4.80 (2.41) 5.05 (2.50) F < 1, p ¼ .72 4.71 (2.58) 4.66 (2.35) 4.45 (2.72) F(2, 253) ¼ 5.01, p ¼ .007, h2p ¼ 04
CQSS 26.62 (6.71) 26.62 (7.01) 26.46 (6.45) F < 1, p ¼ .98 26.89 (7.58) 26.49 (7.27) 26.25 (6.71) F(2, 253) < 1, p ¼ .79, h2p ¼ 00
CDS-12 45.69 (9.17) 45.51 (7.53) 46.80 (8.76) F < 1, p ¼ .56 45.31 (9.70) 45.15 (7.01) 44.16 (9.83) F(2, 253) ¼ 6.38, p ¼ .002, h2p ¼ 05
OCSS total 17.11 (6.82) 18.47 (6.81) 18.71 (6.70) F ¼ 1.36, p ¼ .26 16.75 (6.85) 17.54 (7.03) 16.84 (8.22) F(2, 253) ¼ 2.28, p ¼ .10, h2p ¼ .02
OCSS e preoccupation 9.22 (4.76) 10.01 (5.06) 10.16 (4.94) F < 1, p ¼ .41 9.04 (4.54) 9.69 (5.01) 9.31 (5.30) F(2, 253) ¼ 1.02, p ¼ .36, h2p ¼ .01
OCSS e Compulsive 7.88 (2.76) 8.46 (2.40) 8.55 (2.49) F ¼ 1.73, p ¼ .18 7.87 (2.79) 7.85 (2.65) 7.67 (3.09) F(2, 253) ¼ 4.18, p ¼ .016, h2p ¼ .03
drive

Note. df ¼ degree of freedom; AAT ¼ Approach-Avoidance Task; FTND ¼ Fagerstrøm Test for Nicotine Dependence (0e2 ¼ very low, 3e4 ¼ low; 5 ¼ medium, 6e7 ¼ severe,
8e10 ¼ very severe); CQSS ¼ Commitment to Quitting Smoking Scale; CDS-12 ¼ Cigarette Dependence Scale-12 (12 ¼ low dependence up to 60 ¼ high dependence);
OCSS ¼ Obsessive Compulsive Smoking Scale.

2.6.4. Obsessive Compulsive Smoking Scale (OCSS)
The OCSS was designed to assess compulsive smoking (Hitsman
et al., 2010). It contains 10 items that are allocated to the subscales
(1) preoccupation with smoking and (2) compulsive drive. Internal
consistency was excellent, both for the full (a ¼ .89) and the sub-
scales (preoccupation: a ¼ .87, compulsive drive: a ¼ .85).
2.7. Strategy of data analysis
All participants who withdrew informed consent or did not
answer the questions honestly were excluded from analyses.
Analysis of the primary outcome (cigarettes/day) and all secondary
analyses were conducted using analyses of covariance (ANCOVAs).
Difference scores (pre-post) served as dependent variables and
mean baseline scores as covariates (Field, 2009). This approach was
chosen to avoid regression to the mean and to control for baseline
differences (Borm, Fransen, & Lemmens, 2007; Vickers & Altman,
2001). If the main analyses yielded a significant result, Bonferroni
corrected post-hoc tests were conducted by comparing both AAT
training conditions against the waitlist control group. Intention-to-
treat (ITT) and per protocol (PP) analyses were performed. For ITT
analyses, the data of all participants who completed the baseline
survey and met inclusion criteria were analyzed using the last
observation carried forward (LOCF) procedure. For PP, only data
from completers and participants who used the training at least
once were considered.
3. Results
3.1. Baseline
Baseline demographic and smoking-related characteristics of
the groups are shown in Table 1. As can be seen, randomization was
successful: groups did not differ in any demographic or smoking-
related variable.

Table 4
Subjective appraisal of the programs for both intervention groups.
3.2. Group comparisons

Item Standard Modified 3.2.1. Completion

AAT AAT
(n ¼ 38) (n ¼ 33)
The post-assessment was completed by 156 of the initial 257
participants at baseline (60.7%). Completion rate did not signifi-
Satisfaction with the program in generala 52.6% 42.4%
cantly differ between groups (see Table 1). Non-completers did not
Will you use the program in the future?b 68.4% 48.5%
Do you smoke less?c 28.9% 15.2% differ from completers on any of the variables (all ps > .1) except for
Would you recommend the program …d the FTND which was lower in completers than non-completers at
…to a light smoker? 84.2% 69.7% baseline, t(255) ¼ 2.65, p ¼ .009.
…to a medium smoker? 78.9% 63.6%
…to a strong smoker? 65.8% 51.5%
The program is appropriate for 68.4% 69.7% 3.2.2. PP analyses
self-administration.e Seventeen (of 55) participants of the sAAT and 13 (of 46) par-
My urge to smoke was reduced by 23.7% 9.1% ticipants of the mAAT group had to be excluded due to non-usage of
using the program.e
the training, although they completed both surveys. Groups did not
The description of the program was 94.8% 84.8%
written comprehensively.e differ as to the use of other cessation strategies. Four participants of
I had to overcome myself to use the 36.9% 42.5% the mAAT and five participants of the sAAT group used another
program regularly.e technique in addition to the AAT, c(1) < 1, p ¼ .90.
The program was more helpful than 23.7% 24.2% Results for the main analyses (group comparisons) are sum-
other cessation methods.e
The program was not applicable for me.e 15.8% 36.4%
marized in Table 2. There was a significant improvement across
The design of the program was appealing.e 42.1% 45.5% time in both AAT groups relative to the control group for the pri-
a mary outcome (see Table 2). Post-hoc tests revealed that partici-
Very satisfied, rather satisfied, rather unsatisfied, very unsatisfied, percent are
summed for “satisfied” and “rather satisfied”. pants of the sAAT group smoked significantly fewer cigarettes than
b
Yes; rather yes, rather no, no, percent are summed for “yes” and “rather yes”. the control group, p ¼ .026, whereas there were no differences
c
% yes. between the mAAT and the control group, p ¼ .822. Comparisons
d
I would definitely not recommend it, I would rather not recommend it, I would within groups using one-sample t-tests against zero revealed a
recommend it conditionally, I would recommend it, percent are summed for
“conditionally recommend” and “recommend”.
meaningful reduction in cigarette smoking within the sAAT,
e
true, rather true, rather untrue, untrue, percent are summed for “rather true” t(37) ¼ 2.93, p ¼ .006, and the mAAT group, t(32) ¼ 2.95, p ¼ .006,
and “true”. but not within the control group, t(54) ¼ 1.26, p ¼ .212.
 C.E. Wittekind et al. / J. Behav. Ther. & Exp. Psychiat. 46 (2015) 115e120
For the CDS-12, the main analysis also achieved significance: the
sAAT group endorsed significantly fewer symptoms than the con-
trol group, p ¼ .005, there were no differences between the mAAT
and the control group, p > .9. One sample t-tests against zero
confirmed that only within the sAAT group improvement was
beyond chance, t(37) ¼ 3.78, p ¼ .001 (other groups, ps > .1).
The sAAT group also improved more on the OCSS subscale
Compulsive Drive. The sAAT outperformed the control group,
p ¼ .042, and the mAAT group did not differ from the control group,
p ¼ .313. There were no other significant group differences (see
Table 2). For tobacco dependence as measured with the FTND,
significance was bordered, p ¼ .056, h2p ¼ .05.
3.2.3. ITT analyses
Results of the main analyses remained significant for the main
outcome as well as the CDS-12 (see Table 3). Participants in the
sAAT group had a significantly greater reduction in the number of
cigarettes/day than controls, p ¼ .026. For the CDS-12, the sAAT
group showed significantly greater improvement compared to the
control group, p ¼ .007; however, the mAAT group did not
demonstrate significant improvement compared to the control
group, p > .9. In addition, the sAAT group changed significantly in
the OCSS subscale Compulsive Drive as well as the FTND compared
to the control group (post-hoc: p ¼ .014 and p ¼ .011, see Table 3).
No other group differences emerged (see Table 3).
3.3. Reliability
Internal consistencies (Cronbach's a) for all scales at pre-
assessment (N ¼ 257) ranged from a ¼ .69 to .91. Re-test reli-
ability was determined for the waitlist group. All scales achieved
satisfactory re-test reliabilities (cigarettes per day: r ¼ .95; CQSS:
r ¼ .73; FTND: r ¼ .89; CDS: r ¼ .90; OCSS total: r ¼ .79; OCSS
preoccupation: r ¼ .74; OCSS compulsive drive: r ¼ .78).
4. Discussion
The aim of the present study was to investigate whether a
therapeutic adaptation of the AAT can reduce cigarette smoking.
The PP analyses revealed that relative to the waitlist control group
both training versions of the AAT led to a significantly greater
reduction in cigarette consumption. Our results are in line with
previous studies that successfully retrained action tendencies in
alcohol-dependent individuals (Wiers et al., 2011, 2010). As the
study differed from previous studies in several regards (e.g., drug
under investigation, treatment goal), the significant effect provides
further evidence for a generalized effect of the AAT training.
However, results need to be interpreted carefully as the study lacks
a placebo control condition and one could argue that participants
who engaged in treatment were more motivated to change.
Notwithstanding, the fact that the two versions of the AAT yielded
different outcomes tentatively speaks against the possibility that
improvement reflected a placebo effect alone. Furthermore, in the
study of Wiers et al. (2011) there were no significant differences
between the sham and the no training condition which renders a
placebo effect unlikely. Future studies should apply a more strategic
control group with 50% approach and 50% avoidance movements to
all images.
In comparison to the mAAT and the waitlist control group, both
cigarette dependence and Compulsive Drive significantly decreased
in the sAAT group. Both of these results conform, at least theoret-
ically, to changes within the dual-process system. The latter finding
suggests that the sAAT training increased the perceived control
over smoking urges (see Hitsman et al., 2010, p. 378, for a definition
of compulsive drive) and could tentatively be interpreted as a
119
reduction in craving which, however, was not directly assessed in
the present study.
It is unlikely that significant effects are attributable to the
simultaneous usage of other cessation programs as only five par-
ticipants in the sAAT and four participants in the mAAT group
applied additional cessation techniques. Nevertheless, it cannot be
entirely ruled out that the effects were due to some extraneous
factors unrelated to treatment.
With regard to the efficacy of the two AAT versions, the study
revealed that the sAAT outperformed the mAAT for most measures.
One possible explanation is that direct feedback after each trial
interrupted the continuous movement thereby preventing a
reduction in associative strength. On the other hand, it could be
that perceived poor performance discouraged participants from
further training leading to less favorable cessation results. Unfor-
tunately, both versions did not differ significantly in the ITT ana-
lyses which might be explained by the high attrition rate. However,
to fully establish an effect, ITT analyses are crucial.
First, we have to acknowledge that no active control group was
included; however; there were no significant differences between a
sham and control condition in one study (Wiers et al., 2011)
rendering a placebo effect unlikely. Moreover, we did not assess
behavioral tendencies before and after the training. Although
behavioral changes are more important than changes in cognitive
biases, they become more convincing when mediated by changes in
bias scores (cf. Eberl et al., 2013). This constitutes a serious limita-
tion, however, due to the set-up of the study, behavioral tendencies
could not be assessed. Second, individual use was not tracked as the
intervention was conducted via self-application and frequency of
use was not assessed in the post-assessment. One further limitation
that constrains the explanatory power of our results is that we did
not obtain follow-up data. Finally, the absence of biochemical
verification further limits the validity of the data.
5. Conclusions
As this was the first study that employed the AAT as a retraining
instrument in tobacco dependence, results need to be replicated
with an active control condition before strong conclusions can be
drawn. Given the small effects, it would be interesting to investi-
gate whether the training provides surplus benefit as an adjunct
treatment, a precursor to other smoking cessation interventions or
whether the training yields lower relapse rates when combined
with treatment as usual (cf. Eberl et al., 2013; Wiers et al., 2011).
Overall, our preliminary findings provide a first hint that the
training version of the AAT might be a valuable instrument in
treating tobacco dependence.
Acknowledgments
We would like to thank all participants of the study. We would
also like to thank the reviewers for their constructive feedback and
valuable comments.
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