Proximal and Long-Term Participants' Perspectives on Approach Bias Modification for Smoking Cessation: Qualitative...

Approach bias modification (ApBM) aims to target maladaptive approach tendencies toward substance-related cues and has increasingly been examined as an adjunctive intervention for substance use disorders, including nicotine use. However, although participants' subjective experiences of ApBM are likely to influence both its effectiveness and successful implementation, they have rarely been systematically investigated.

This study aimed to explore both proximate and long-term subjective training experiences reported by participants from 2 previously conducted randomized controlled trials of ApBM for smoking cessation. Training experiences were explored across 2 delivery modalities (virtual reality and smartphone app) and compared with those reported in matched sham training conditions.

Participants were invited to provide open-ended feedback immediately following the intervention and up to 7 weeks after study entry (proximate feedback), as well as again 4 years later (long-term feedback). Thematic analysis was conducted to identify core themes, complemented by exploratory frequency and descriptive quantitative analyses comparing ApBM and sham conditions.

In total, 87 (ApBM: n=45; sham: n=42) of the 178 participants included in the randomized controlled trials provided proximate (7-week follow-up) feedback, and 63 (ApBM: n=33; sham: n=30) provided long-term (4-year follow-up) feedback; 104 participants contributed feedback at least once. Four overarching themes were identified, with the fourth emerging only in long-term reflections: (1) perceived treatment effects, spanning beneficial changes and a perceived lack of effects; (2) mechanisms of action, including presumed working mechanisms and impeding factors; (3) feedback on the training and study experience; and (4) attribution of effects to training-specific or external factors. Overall, participants engaged extensively in reflecting on potential mechanisms underlying the training, their relation to therapeutic outcomes, and opportunities for improving future interventions. Exploratory frequency analyses indicated that participants in the ApBM group more often suggested improvements to the training, whereas participants in the sham condition more frequently reported impeding factors, particularly difficulties understanding the training rationale. Quantitative training evaluations were generally more favorable for ApBM than for sham training, as reflected in a significantly higher overall evaluation score. In particular, ApBM received higher ratings for its perceived effectiveness in reducing smoking and its applicability to everyday situations.

This study provides novel insights into how ApBM for smoking is experienced both shortly after training and years later. To our knowledge, this is the first study in the context of cognitive bias modification, including ApBM, to examine subjective experiences over a multiyear time frame. The findings highlight the importance of participants' understanding of the training rationale and underscore the value of incorporating participants' perspectives into the development and evaluation of ApBM interventions.