The who and how of attentional bias in cannabis users: associations with severity, craving, and interference control

Background and Aim. Cognitive and motivational processes are thought to underlie cannabis use disorder (CUD), but research assessing how cognitive processes (e.g. interference control (IC)) interact with implicit motivational processes (e.g. attentional bias (AB)) and explicit motivation (i.e. craving) is lacking. We assessed the presence of AB in cannabis users with varying use severity and tested models of moderation, mediation, and moderated mediation to assess how AB, craving, and IC interact in their association with measures of cannabis use. Design. Cross-sectional. Setting and Participants. Eight studies performed in the Netherlands including never-sporadic, occasional (≤ 1/month), and regular cannabis users (≥ 2/week), and individuals in treatment for CUD were combined (N = 560; 71% male). Measurements. All studies included a Classic Stroop task to assess IC, a Cannabis Stroop task to assess AB, and a pre- and post-session measure of craving. Both heaviness of cannabis use (grams per week) and severity of use related problems (CUDIT-R scores) were included. Findings. Only those in treatment for CUD showed an AB and group differences in AB were only observed when comparing those in treatment with never to sporadic users. Looking at occasional-regular users, IC was negatively associated with heaviness, but not severity of use. There was no direct association between AB and measures of cannabis use. However, average craving during the session, but not session induced craving, mediated this association between AB and heaviness as well as severity of use; higher AB was associated to heavier use and more severe problems through increased craving. Conclusions. AB was only present in cannabis users with the most severe problems and craving mediated the association between AB and both heaviness and severity of use in occasional to regular users. Furthermore, the association of IC with heaviness but not severity of use may point to sub-acute effects.