Fear-related associations in children of parents with an anxiety disorder.

BACKGROUND AND OBJECTIVES: Children of parents with an anxiety disorder are at elevated risk for developing an anxiety disorder themselves. According to cognitive theories, a possible risk factor is the development of schema-related associations. This study is the first to investigate whether children of anxious parents display fear-related associations and whether these associations relate to parental anxiety. METHODS: 44 children of parents with panic disorder, 27 children of parents with social anxiety disorder, and 84 children of parents without an anxiety disorder filled out the SCARED-71, and the children performed an Affective Priming Task. RESULTS: We found partial evidence for disorder-specificity: When the primes were related to their parent's disorder and the targets were negative, the children of parents with panic disorder and children of parents with social anxiety disorder showed the lowest error rates related to their parents' disorder, but they did not have faster responses. We did not find any evidence for the expected specificity in the relationship between the parents' or the children's self-reported anxiety and the children's fear-related associations, as measured with the APT. LIMITATIONS: Reliability of the Affective Priming Task was moderate, and power was low for finding small interaction effects. CONCLUSIONS: Whereas clearly more research is needed, our results suggest that negative associations may qualify as a possible vulnerability factor for children of parents with an anxiety disorder.

Implementing Approach-Bias Modification as Add-On to Varieties of Clinical Treatment for Alcohol Use Disorders: Results of a Multicenter RCT.

INTRODUCTION: Abstinence rates after inpatient treatment for alcohol use disorder (AUD) are modest (1-year rate around 50%). One promising approach is to re-train the automatically activated action tendency to approach alcohol-related stimuli (alcohol-approach bias) in AUD patients, as add-on to regular treatment. As efficacy has been demonstrated in well-controlled randomized controlled trials, the important next step is to add alcohol-approach-bias modification (alcohol-ApBM) to varieties of existing treatments for AUD. Therefore, this prospective, multicenter implementation-RCT examined whether adding alcohol-ApBM to regular treatments (various abstinence-oriented treatments including both individual and group-based interventions) would significantly increase abstinence rates compared to receiving regular treatment only, in a variety of naturalistic settings with different therapeutic approaches. METHODS: A total of 1,586 AUD inpatients from 9 German rehabilitation clinics were randomly assigned to receive either ApBM in addition to regular treatment or not. Training satisfaction of patients and therapists was measured after training. Success rates were determined at 3, 6, and 12 months post-treatment. RESULTS: Return rates of the post-treatment assessments varied greatly between clinics, often being low (18-76%). Nevertheless, ApBM significantly increased success rates after 3 months. After 6 and 12 months, the differences were not significant. ApBM was evaluated mostly positively by patients and therapists. DISCUSSION/CONCLUSION: ApBM was an effective add-on to regular treatment of AUD at 3 months follow-up, across a variety of AUD treatment settings. However, low return rates for the clinical outcomes reduced the effect size of ApBM considerably. The application of ApBM proved feasible in varying clinical settings, offering the opportunity to modify automatic processes and to promote abstinence.

Interpretation biases in childhood spider fear: Content-specificity, priming, and avoidance.

BACKGROUND AND OBJECTIVES: The relation between fear and interpretation bias has been widely studied in children. However, much less is known about its content-specificity and how interpretation biases predict variance in avoidance. The current study examined different interpretation bias tasks, the role of priming and the ability of the interpretation bias tasks to predict spider fear-related avoidance behaviour. METHODS: 169 children with varying levels of spider fear performed a behavioural avoidance task, two versions of the Ambiguous Scenarios Task (AST; with and without priming), and a size and distance estimation task. RESULTS: Both versions of the AST and the size-estimation were significantly related to self-reported spider fear and avoidance. These relations were content-specific: children with higher levels of spider fear had a more negative interpretation bias related to spider-related materials than to other materials, and a more negative bias than children with lower levels of spider fear. Furthermore, self-reported spider fear, the AST with priming, and the size-estimation predicted unique variance in avoidance behaviour. LIMITATIONS: Children varied in their level of spider fear, but clinical diagnoses of spider phobia were not assessed. The participants of this study were not randomly selected, they were children of parents with panic disorder or social anxiety disorder or no anxiety disorder and could therefore partly be seen as children at risk. CONCLUSIONS: The results support cognitive models of childhood anxiety and indicate that both controlled and automatic processes play an important role in fear-related behaviour.

Although I know it: Social anxiety is associated with a deficit in positive updating even when the cost of avoidance is Obvious.

Social anxiety (SA) is associated with difficulties in positively updating negative social information when new information and feedback about chosen options (actual decisions) are received. However, it is unclear whether this difficulty persists when hidden information regarding unchosen options is explicitly presented. The aim of the current study was to address this gap. Participants (Mturk; n = 191) completed a two-phases novel task. In the task, participants chose to approach or avoid people, represented by images of faces. During the initial (learning) phase, participants learned, in a probabilistic context, which people are associated with negative outcomes and should be avoided, and which are associated with positive outcomes and should be approached. During the subsequent updating phase, people previously associated with negative outcomes became associated with positive outcomes and vice versa. Importantly, participants received feedback not only on their approach (actual) decisions, but also on their avoidance (counter-factual) decisions (e.g., approaching this person would have been beneficial). The results revealed that even when the consequences of avoidance were explicitly presented, SA was associated with difficulty in positive updating of social information. The findings support the view that biased updating of social information is a change-resistant mechanism that may underlie the maintenance of SA.

Watch out! A path from anxiety to anorexia nervosa through biased attention?

OBJECTIVE: Evidence points towards heightened anxiety and attention biases (AB) towards disorder-specific (threatening) stimuli in patients with anorexia nervosa (AN). To date, it is unclear how anxiety and AB interact in eating disorders (ED). The present study tests the causal role of anxiety by inducing anxiety before a dot-probe task with either ED-specific stimuli or unspecific negative (threat-related) information. We expected that anxiety would elicit AB for ED-specific, but not for unspecific threat-related stimuli. METHODS: Adolescents with AN (AN, n = 32) or depression (DEP, n = 27) and healthy controls (HC, n = 29) underwent an anxiety induction or a low anxiety control task before a pictorial dot-probe task with either under-/overweight body-related pictures or non-disorder-related threatening pictures (angry faces). BMI, level of ED symptoms, anxiety, stress, and depression were assessed at baseline. RESULTS: The anxiety induction did not affect the observed attention pattern. AN showed an AB towards underweight body pictures compared to HC, whereas no disorder-unspecific threat-related AB emerged. Regression analyses revealed that only anxiety predicted the AB towards underweight body pictures. DISCUSSION: Further experimental research may integrate eye tracking as an additional tool, or collect information on body dissatisfaction to obtain a better understanding of how anxiety biases attention.

How pre-processing decisions affect the reliability and validity of the approach-avoidance task: Evidence from simulations and multiverse analyses with six datasets.

Reaction time (RT) data are often pre-processed before analysis by rejecting outliers and errors and aggregating the data. In stimulus-response compatibility paradigms such as the approach-avoidance task (AAT), researchers often decide how to pre-process the data without an empirical basis, leading to the use of methods that may harm data quality. To provide this empirical basis, we investigated how different pre-processing methods affect the reliability and validity of the AAT. Our literature review revealed 108 unique pre-processing pipelines among 163 examined studies. Using empirical datasets, we found that validity and reliability were negatively affected by retaining error trials, by replacing error RTs with the mean RT plus a penalty, and by retaining outliers. In the relevant-feature AAT, bias scores were more reliable and valid if computed with D-scores; medians were less reliable and more unpredictable, while means were also less valid. Simulations revealed bias scores were likely to be less accurate if computed by contrasting a single aggregate of all compatible conditions with that of all incompatible conditions, rather than by contrasting separate averages per condition. We also found that multilevel model random effects were less reliable, valid, and stable, arguing against their use as bias scores. We call upon the field to drop these suboptimal practices to improve the psychometric properties of the AAT. We also call for similar investigations in related RT-based bias measures such as the implicit association task, as their commonly accepted pre-processing practices involve many of the aforementioned discouraged methods. HIGHLIGHTS: • Rejecting RTs deviating more than 2 or 3 SD from the mean gives more reliable and valid results than other outlier rejection methods in empirical data • Removing error trials gives more reliable and valid results than retaining them or replacing them with the block mean and an added penalty • Double-difference scores are more reliable than compatibility scores under most circumstances • More reliable and valid results are obtained both in simulated and real data by using double-difference D-scores, which are obtained by dividing a participant's double mean difference score by the SD of their RTs.

Approach-Bias Retraining and Other Training Interventions as Add-On in the Treatment of AUD Patients.

In the past two decades, a variety of cognitive training interventions have been developed to help people overcome their addictive behaviors. Conceptually, it is important to distinguish between programs in which reactions to addiction-relevant cues are trained (varieties of cognitive bias modification, CBM) and programs in which general abilities are trained such as working memory or mindfulness. CBM was first developed to study the hypothesized causal role in mental disorders: by directly manipulating the bias, it was investigated to what extent this influenced disorder-relevant behavior. In these proof-of-principle studies, the bias was temporarily modified in volunteers, either temporarily increased or decreased, with corresponding effects on behavior (e.g., beer consumption), in case the bias was successfully manipulated. In subsequent clinical randomized controlled trials (RCTs), training (away from the substance vs. sham training) was added to clinical treatment. These studies have demonstrated that CBM, as added to treatment, reduces relapse with a small effect of about 10% (similar effect size as for medication, with the strongest evidence for approach-bias modification). This has not been found for general ability training (e.g., working memory training), although effects on other psychological functions have been found (e.g., impulsivity). Mindfulness also has been found to help people overcome addictions, and different from CBM, also as stand-alone intervention. Research on (neuro-)cognitive mechanisms underlying approach-bias modification has pointed to a new perspective in which automatic inferences rather than associations are influenced by training, which has led to the development of a new variety of training: ABC training.

Pandemic related changes in social interaction are associated with changes in automatic approach-avoidance behaviour.

People's natural tendencies to either approach or avoid different stimuli in their environment are considered fundamental motivators of human behaviour. There is a wealth of research exploring how changes in approach and avoidance motivational orientations impact behaviour with consequences for wellbeing. However, research has seldom explored this relationship in reverse. The COVID-19 pandemic offered a unique opportunity to explore whether widespread changes in social behaviour are associated with changes in automatic approach-avoidance tendencies over time. We gathered online survey data on people's adherence to 7 of the prescribed social restrictions set out by the UK government and people's automatic approach-avoidance tendencies in response to different stimuli (sad/happy faces and social scenes) at three time points during the COVID-19 pandemic. Reduced-overall-interaction (digital and in person) was found to be significantly associated with faster avoidance relative to approach of sad faces. The results suggest that automatic approach-avoidance tendencies may function to protect people against the typically negative experience of reduced social interaction, with important implications for understanding public resilience during times of crisis, and beyond.

Study protocol for approach bias retraining for nicotine addiction among dual combustible and electronic cigarette users.

BACKGROUND: 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. Yet, most CC smokers who initiate ECIG use do not fully transition from CC to ECIG, despite intending to quit CC completely. Retraining approach bias, or the approach action tendency toward stimuli related to the substance of interest, has been effective in alcohol and CC use treatments. However, approach bias retraining for both CC and (ECIG) users has not been explored. Therefore, the objective of the study is to evaluate the initial efficacy of approach bias retraining among dual CC and ECIG users. METHODS: Eligible dual CC/ECIG using adults (N = 90) will complete a phone-screener, baseline assessment, 4 treatment sessions over 2 weeks, ecological momentary assessments (EMAs) post-intervention, and follow-ups at 4- and 6-week post-intervention. Participants will be assigned to one of three conditions at baseline: (1) CC + ECIG retraining; (2) CC only retraining; and (3) sham retraining. Participants will engage in a self-guided quit attempt to abstain from all nicotine products starting at treatment session 4. CONCLUSIONS: The study may lead to a more effective treatment for at-risk nicotine users while simultaneously isolating explanatory mechanisms. The findings should guide advances in the theoretical conceptualization of nicotine addiction for dual users and mechanisms involved in maintaining and abstaining from CC and ECIG, and provide initial effect size data for a brief intervention, thus providing necessary data for a large-scale follow-up trial. Clinical Trials ID: NCT05306158.

Does selective inhibition training reduce relapse rates when added to standard treatment of alcohol use disorder? A randomized controlled trial.

BACKGROUND: Alcohol-dependent individuals tend to selectively approach alcohol cues in the environment, demonstrating an alcohol approach bias. Because approach bias modification (ApBM) training can reduce the approach bias and decrease relapse rates in alcohol-dependent patients when added to abstinence-focused treatment, it has become a part of regular treatment. Moreover, in selective inhibition (SI) training, responses to one category of stimuli (i.e., alcohol stimuli) are selectively inhibited in an adapted Go/No-Go task. SI-Training has been found to effectively devalue the inhibited category and to reduce consumption of alcohol among social drinkers. This study investigated whether SI-Training can further improve the effects of treatment as usual that includes ApBM, and if so, whether the effect is mediated by a devaluation of the inhibited alcohol stimuli. METHODS: Abstinent alcohol-dependent inpatients (N=434) were randomly assigned to receive 6 sessions of either active (n = 214, 32% female) or sham (n = 220, 38% female) SI-Training, in addition to standard treatment that includes active ApBM. Ratings were used to assess changes in the evaluation of alcohol stimuli after the training. Relapse rates were assessed 3 and 12 months after treatment discharge. RESULTS: Alcohol stimuli were rated negatively before and after the training, and the training did not influence these ratings. Evaluation of nonalcoholic drinks became more positive after active SI-Training. Both ApBM and SI-Training showed the expected training effects on reaction times. Contrary to expectations, SI-Training conditions did not yield different abstinence rates 3 or 12 months after treatment. CONCLUSIONS: We found no evidence supporting the hypothesis that SI-Training amplifies the relapse-preventing effect of ApBM. Moreover, alcohol stimuli were rated negatively before and after treatment and were not influenced by SI-Training.

How context, mood, and emotional memory interact in depression: A study in everyday life.

Cognitive theories of depression hold that negative contextual triggers (e.g., stressful events) induce more negative and less positive mood, in turn instigating negatively biased memories. However, context-related variability in mood and emotional memory has received insufficient attention, while the dynamic interaction between these factors plays a crucial role in the kindling of new depressive episodes. Experience Sampling Method (ESM) for repeated, daily life measures of context, mood, and autobiographic emotional memory was used in 46 currently depressed, 90 remitted-depressed, and 55 never-depressed individuals. Currently depressed individuals showed strongest negative processing style and never-depressed most positive, with remitted-depressed patients scoring intermediate. The moderated mediation model indicated that context appraisal had a direct effect on the appraisal of the recalled event (i.e., our operationalization of emotional memory), which was mediated by positive (but hardly by negative) mood and was independent of depression status. This mediation strength was relatively similar to the strength of the direct effect of context on memory. Results are in line with cognitive theories of depression. Especially context seems important for emotional memory. The association between context, mood, and memory, however, may be independent of depression status. Yet, the "level" of mood, context, and event appraisal does depend on depression status. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Touchscreen-based approach-avoidance responses to appetitive and threatening stimuli.

BACKGROUND AND OBJECTIVES: Individuals are thought to be biased towards approaching positive stimuli and avoiding negative stimuli. Yet, it is unclear whether this general pattern applies to all stimulus classes or whether biases are more specific. We expected significant approach biases towards two types of positive stimuli, appetitive foods and butterflies; and avoidance biases away from two types of negative stimuli, spoiled foods and spiders. METHODS: A touchscreen-based Approach-Avoidance Task (AAT), using hand gestures toward or away from stimuli assessed biases. Questionnaires and image ratings assessed individual differences in stimulus evaluations. RESULTS: Approach biases for butterflies and appetitive foods were found, the latter being strongest towards individually liked foods. There was no avoidance bias for spoiled foods. An avoidance bias for spiders was found in individuals with elevated spider fear. LIMITATIONS: Incomplete counterbalancing precluded direct comparison between both positive and negative stimuli. CONCLUSIONS: Behavioural biases in the touchscreen AAT generally co-vary with individuals' affective evaluation of the stimuli. Approach biases were elicited by positive stimuli independently of whether they were regularly (foods) or rarely (butterflies) approached in everyday life. This may hint towards a tendency to approach positive stimuli regardless of the specific category, whereas avoidance biases may be more stimulus specific.

An experimental test of integrating imagery with approach bias modification for alcohol: A cautionary tale.

OBJECTIVES: In terms of dual process models, behaviour can be conceived of as the outcome of an interplay between reflective, top-down and impulsive, bottom-up processes. Behaviour change interventions may benefit from targeting both types of processes in a coherent way. One approach to this, in the context of reducing hazardous drinking, is to combine imagery involving real-life situations involving alcohol with the simple actions involved in Approach Bias Modification (ApBM), a form of Cognitive Bias Modification. DESIGN: We developed and tested a version of this Imagery-enhanced Approach Bias Modification (IApBM) in an experimental design, with two independent factors: imagery versus control and ApBM versus control training components (N = 139). METHODS: An effect of integrating the training factors was hypothesized on the alcohol-approach bias of an alcohol Approach-Avoidance Task. Further exploratory analyses were performed for the bias on alcohol-related Single Attribute Implicit Association Tests and on alcohol-related questionnaires. Finally, the psychometric properties of an imagery interference effect during training were explored. RESULTS: Results showed no benefit of the training and in fact suggested a negative interaction in which combining the training components appeared to block reductions in craving effected by each in isolation. The reliability of the imagery-related interference effect was high and the effect was correlated with alcohol-related scales. CONCLUSIONS: In conclusion, it appears that interference between training components decreases their individual effects when combining imagery and ApBM in the current way. The imagery-related interference effects that could be measured during training conditions may be useful as an implicit measure of automatic processes underlying hazardous drinking.

Face masks impair facial emotion recognition and induce specific emotion confusions.

Face masks are now worn frequently to reduce the spreading of the SARS-CoV-2 virus. Their health benefits are undisputable, but covering the lower half of one's face also makes it harder for others to recognize facial expressions of emotions. Three experiments were conducted to determine how strongly the recognition of different facial expressions is impaired by masks, and which emotions are confused with each other. In each experiment, participants had to recognize facial expressions of happiness, sadness, anger, surprise, fear, and disgust, as well as a neutral expression, displayed by male and female actors of the Radboud Faces Database. On half of the 168 trials, the lower part of the face was covered by a face mask. In all experiments, facial emotion recognition (FER) was about 20% worse for masked faces than for unmasked ones (68% correct vs. 88%). The impairment was largest for disgust, followed by fear, surprise, sadness, and happiness. It was not significant for anger and the neutral expression. As predicted, participants frequently confused emotions that share activation of the visible muscles in the upper half of the face. In addition, they displayed response biases in these confusions: They frequently misinterpreted disgust as anger, fear as surprise, and sadness as neutral, whereas the opposite confusions were less frequent. We conclude that face masks do indeed cause a marked impairment of FER and that a person perceived as angry, surprised, or neutral may actually be disgusted, fearful, or sad, respectively. This may lead to misunderstandings, confusions, and inadequate reactions by the perceivers.

Approach bias retraining to augment smoking cessation: A pilot randomized controlled trial.

BACKGROUND: Approach tendency to smoking-related cues has been associated with greater cravings, nicotine dependence, and the likelihood of relapse. In this pilot randomized clinical trial, we examined the efficacy of approach bias retraining (ABR; i.e., increasing avoidance tendency) for enhancing standard smoking cessation treatment (ST). METHODS: Adult smokers (N = 96) motivated to quit were randomly assigned to 7 weekly in-person treatment sessions consisting of either (1) cognitive-behavioral therapy for smoking cessation (ST) and ABR (ST+ABR) or ST and sham retraining (ST+Sham). All participants also received optional nicotine replacement therapy for up to 8 weeks following the scheduled quit date (week 6). We measured avoidance tendency from weeks 1-7. Point prevalence abstinence (PPA) and prolonged abstinence (PA) were measured up to 3 months following the quit attempt (week 18 follow-up). RESULTS: Consistent with our hypothesis, participants in ST+ABR evidenced higher abstinence rates than those in ST+Sham at the final follow-up (b=0.71, 95 % CI: [0.14, 1.27], t[1721]=2.46, p = 0.014, OR=2.03, 95 % CI: [1.15, 3.57]). Specifically, PPA and PA rates were 50 % and 66 % in ST+ABR compared to 31 % and 47 % in ST+Sham. As expected, participants assigned to the ST+ABR condition also showed a greater training-compatible increase in avoidance tendency scores relative to those assigned to the ST+Sham condition (b=248.06, 95 % CI: [148.51, 347,62], t[84]=4.96, p < .001). CONCLUSIONS: The current pilot randomized clinical trial provides initial evidence for the efficacy of integrating standard smoking cessation with ABR. These findings encourage the testing of the long-term efficacy and mechanisms of action of this integrated intervention.

Corrigendum to "Approach bias retraining to augment smoking cessation: Study protocol for a randomized controlled trial" [Contemp. Clin. Trials Commun. 14 (2019) 100340].

[This corrects the article DOI: 10.1016/j.conctc.2019.100340.].

I C U but I don't care: Callous-unemotional traits and approach-avoidance behaviour in conduct disorder.

BACKGROUND AND OBJECTIVES: Conduct disorder (CD) is associated with deficits in social-emotional behaviour, such as increased levels of aggression. Callous-unemotional (CU-) traits foster those deficits and contribute to severe rates of instrumental aggression in CD. Previous studies of that increase in aggression have mainly focused on intentional aspects of behaviour. Unintentional behaviour, such as automatic approach and avoidance, has not been taken into account despite being highly relevant for behaviour. Therefore, the relevance of CU-traits for automatic actions and the feasibility of an approach-avoidance-task to measure those actions in CD-patients were investigated in a study series. METHODS: Study 1 22 CD-patients executed an approach-avoidance task, where participants pushed or pulled pictures of emotional faces using a joystick. CU-traits were assessed via parent-report. Study 2 28 CD-patients and 19 typically developing children (TD) executed the AAT. Again, CU-traits were assessed via parent-report. RESULTS: The AAT was a feasible instrument to measure automatic action tendencies and revealed that, while TD-children showed an avoidance bias towards angry faces, CD-patients showed a lack of automatic avoidance of anger. Across the whole sample (TD and CD combined), CU-traits predicted less threat avoidance. LIMITATIONS: The small sample size may have limited the power to detect smaller approach-avoidance tendencies towards other emotions. CONCLUSIONS: The findings suggest that CD is associated with a lack of automatic avoidance of social threat and that CU-traits predict that lack of avoidance. Divergent automatic threat responding might underlie the extreme levels of instrumentally aggressive behaviour observed in CD-patients with distinctive CU-traits.

Facing Uncertainty: Interpretation of Ambiguous Emotional Faces in Childhood Social Anxiety Disorder.

OBJECTIVE: The current study examined whether children with a social anxiety disorder (SAD) demonstrate divergent facial emotion processing and a disorder-specific negative interpretation bias in the processing of facial emotional expressions. This study aimed to overcome previous study limitations by including both a nonsocially anxious control group and a healthy control group to examine whether childhood SAD is characterized by a general emotion labeling deficit, and/or by a negative interpretation bias, indicated by systematic misclassifications, or a lower threshold for recognizing threatening emotions. METHOD: Participants were 132 children aged 7-12 years (Mage = 9.15; 45.5% female). Children with SAD (n = 42) were compared to children with other, nonsocial, anxiety disorders (n = 40) and healthy control children (n = 50) on a novel facial emotion recognition task. Children judged ambiguous happy/neutral, angry/neutral and fear/neutral faces that were morphed at different intensities (10%, 30%, 50%, 70%). RESULTS: Children with SAD did not differ from other groups in their accuracy of identifying emotions. They did not show systematic misclassifications or a heightened sensitivity to negative, threatening faces either. Rather, children with nonsocial anxiety disorders showed a generally heightened sensitivity to emotional faces. CONCLUSIONS: The current study does not provide evidence for a general deficit in labeling of emotional faces in childhood SAD. Childhood SAD was not characterized by an interpretation bias in processing emotional faces. Children with nonsocial anxiety disorders may benefit from assistance in accurately interpreting the degree of emotionality in interpersonal situations.

"Push it!" or "Hold it!"? A comparison of nicotine-avoidance training and nicotine-inhibition training in smokers motivated to quit.

RATIONALE: Recently, experimental paradigms have been developed to strengthen automatic avoidance or inhibitory responses for smoking cues. However, these procedures have not yet been directly compared regarding their effectiveness and mechanisms of action. OBJECTIVE: This study compared the effects of avoidance vs. inhibitory training as an add-on to a brief smoking cessation intervention. The standard Approach-Avoidance-Task (AAT) was adapted for both training types and control conditions. METHODS: One hundred twenty-four smokers attended behavioral counseling for smoking cessation and were thereafter randomized to one of four training conditions: avoidance-AAT, sham-avoidance-AAT, inhibition-AAT, sham-inhibition-AAT. During a 2-week training period including five training sessions, smokers in the avoidance-AAT trained to implicitly avoid all smoking-related cues, while smokers in the inhibition-AAT trained to implicitly inhibit behavioral response to smoking cues. During sham training, no such contingencies appeared. Self-report and behavioral data were assessed before and after training. Cigarette smoking and nicotine dependence were also assessed at 4- and 12-week follow-ups. RESULTS: At posttest, avoidance training was more effective in reducing daily smoking than inhibition training. However, this difference was no longer evident in follow-up assessments. All training conditions improved other smoking- and health-related outcomes. Neither training changed smoking-related approach biases or associations, but approach biases for smoking-unrelated pictures increased and Stroop interference decreased in all conditions. Smoking devaluation was also comparable in all groups. CONCLUSIONS: Avoidance training might be slightly more effective in reducing smoking than inhibitory training. Overall, however, all four training types yielded equivalent therapy and training effects. Hence, a clear preference for one type of training remains premature.