Addictive Behaviors 48 (2015) 58–61
Contents lists available at ScienceDirect
Addictive Behaviors
Short Communication
Psychometric evaluation of a standardized set of alcohol cue photographs to assess craving David E. Lovett ⁎, Lindsay S. Ham, Jennifer C. Veilleux University of Arkansas, USA
H I G H L I G H T S • • • •
This study presents psychometric properties of a new set of alcohol photo cues. Images of alcohol standardized with beverage as the primary focus of each image Alcohol cue craving ratings formed one internally consistent factor. Findings supported convergent, incremental, and discriminant validity of cues.
a r t i c l e
i n f o
Available online 8 May 2015 Keywords: Alcohol Craving Cue Photographs Standardized Reactivity
a b s t r a c t Introduction: Research using alcohol-related visual stimuli has been limited due to a lack of published studies examining the psychometric properties of alcohol cues. The primary aim of the current study was to examine the factor structure, validity, and reliability of craving ratings following exposure to alcohol cues (including beer, wine, hard liquor, and mixed drinks) in an alcohol cue-reactivity paradigm. Methods: U.S. adults ages 21-69 [N = 195; Mage = 32.19, SD = 10.63; 74.4% male; 56.4% Asian/Pacific Islander, 34.9% White (non-Hispanic), 4.6% Other, 2.0% Hispanic/Latino, 1.5% Native American/Alaskan Native, and 0.5% African-American] completed questionnaires and provided craving, arousal, and valence ratings following alcohol, positive, negative and neutral cues in a web-based study. Results: The alcohol craving ratings following alcohol cues formed one internally consistent factor. Convergent and incremental validity was supported as alcohol cue craving ratings were positively correlated with general craving, past-year hazardous alcohol use, and behavioral activation facets, even while controlling for neutral cue craving ratings and other related variables. Alcohol craving was significantly higher following alcohol cues compared to neutral cues and unrelated to behavioral inhibition, supporting discriminant validity. Conclusions: These findings provide support that the alcohol cues we developed are reliable and valid stimuli for the use in alcohol cue reactivity paradigms. Future research assessing alcohol cue reactivity using this validated photographic cue set may facilitate a greater understanding of the affective processes associated with alcohol use and allow for more targeted behavioral change interventions for alcohol-related problems. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Alcohol craving or one's “desire or urge to drink,” is associated with severity of alcohol use problems and impacts a person's approach or avoidance of alcohol consumption (Kramer et al., 2010; Wiers et al., 2007). While researchers have examined reactions to alcohol cues, the lack of a validated alcohol cue set to assess alcohol craving has hindered the interpretations that can be drawn across studies. Alcohol cue reactivity studies examining pictorial stimuli have included alcoholrelated cues sourced from the following: (1) standardized picture sets ⁎ Corresponding author at: Department of Psychological Science, University of Arkansas, Fayetteville, AR 72701, USA. Tel.: +1 479 575 4256. E-mail address: [email protected] (D.E. Lovett).
http://dx.doi.org/10.1016/j.addbeh.2015.05.002 0306-4603/© 2015 Elsevier Ltd. All rights reserved.
that were not developed with the intention of assessing craving (e.g., Normative Affective Picture System [NAPS; Stritzke, Breiner, Curtin, & Lang, 2004] and International Affective Picture System [IAPS; Lang, Bradley, & Cuthbert, 2008]; Drobes, Carter, & Goldman, 2009), (2) internet and stock photography (e.g., Carter, 2010; Drobes et al., 2009; Pulido, Brown, Cummins, Paulus, & Tapert, 2010), or (3) researcher-created photographs (e.g., Billieux et al., 2011). Some of these studies used alcohol cues without supporting psychometric evidence (Carter, 2010; Drobes et al., 2009; Grüsser, Heinz, & Flor, 2000). Other researchers provided some psychometric data related to alcohol cues; however, aspects related to the content presented within the photographs are problematic and could be improved to provide a more precise and comprehensive examination of alcohol cue reactivity (Billieux et al., 2011; Carter, 2010; Lee, Namkoong, Lee, An, & Lee, 2006).
D.E. Lovett et al. / Addictive Behaviors 48 (2015) 58–61
Of the available work to date focused on developing and evaluating a set of standardized alcohol photo cues (e.g., Billieux et al., 2011; Lee et al., 2006; Pulido et al., 2010), there remain several limitations. For example, the content of many photo cues used also include social cues, branding and labels used in advertising, and other environmental stimuli (Billieux et al., 2011; Lee et al., 2006; Pulido et al., 2010) that while potentially enhancing ecological validity, pose threats to internal validity. Further, many studies used idiographic stimuli based on each participant's preferred beverage (Coffey, Saladin, Libet, Drobes, & Dansky, 1999; Payne et al., 1992; Pomerleau, Fertig, Baker, & Cooney, 1983; Schulze & Jones, 2000) without first fully understanding the effect of personalized cues compared to standardized cues. Finally, there has been little attention to assessing craving following alcohol cue presentation, even with the repeated assertion that craving ratings are a necessary component for substance stimuli validation (e.g., nicotine: Carter et al., 2006; alcohol: Carter, 2010). Taken together, there is a lack of empirical work focused on validating a standardized alcohol cue picture set. 1.1. Current study We aimed to evaluate the psychometric properties for a set of alcohol cues for use in non-alcohol dependent samples. The present study expanded upon previous alcohol cue standardization studies (Billieux et al., 2011; Lee et al., 2006; Pulido et al., 2010) by (1) examining a set of alcohol beverage cues that adequately excluded extraneous influences (e.g., advertising, branding, social depictions, gender stereotypes, and inclusion of cigarette smoking); (2) providing a more comprehensive assessment of validity and reliability; (3) adding the measurement of subjective craving alongside valence and arousal following each cue; and (4) including commonly consumed beverages (e.g., beer, wine, liquor, mixed drinks) in the alcohol cue set. We examined factor structure, internal consistency, as well as convergent, incremental, and discriminant validity to evaluate the psychometric properties of the alcohol cues. 2. Method 2.1. Participants and procedures U.S. adults (N = 195) of ages 21–69 [Mage = 32.19, SD = 10.63; 74.4% male; 56.4% Asian or Pacific Islander, 34.9% White (non-Hispanic), 4.6% Other, 2% Hispanic/Latino, 1.5% Native American/Alaskan Native, and 0.5% African-American] were recruited through Mechanical Turk© (MTurk®). Participants reported past 30-day alcohol use, denied past4-hour alcohol use, denied being an alcoholic or abstaining from alcohol,
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and had an MTurk® “quality rating” of ≥ .90. Most participants had a two-year college degree or higher (77.4%) and were employed (82.1%). The participants were directed to Qualtrics® for informed consent, the online study, and debriefing. Upon providing informed consent, the participants completed self-report questionnaires and a cue rating task in which the participants were shown a series of photographs and asked to provide valence, arousal, and craving ratings after each cue. Twenty alcohol cues (five pictures from each of four alcohol beverage categories) and 12 pictures from each of three IAPS categories (positive, negative, neutral) were presented in randomized order. The participants were debriefed and compensated $0.69, based on the average MTurk® rate. 2.2. Measures The Desires for Alcohol Questionnaire (DAQ; Love, James, & Willner, 1998) measured desire to drink, ability to control drinking, anticipation of positive drinking outcomes, and anticipation of relief from negative affect or alcohol withdrawal. The DAQ has demonstrated concurrent validity and reliability among individuals with and without an alcohol use disorder (Kramer et al., 2010). See Table 1 for means, standard deviations, and Cronbach's alphas for multi-item self-report measures. The Alcohol Use Disorder Identification Test (AUDIT; Babor, HigginsBiddle, Saunders, & Monteiro, 2001) is a well-established measure of past-year hazardous alcohol use (i.e., alcohol use quantity/frequency, dependence symptoms, and negative consequences). The Behavioral Inhibition System/Behavioral Activation System (BIS/BAS; Carver & White, 1994) was used to measure individual differences in the sensitivity and regulation of both aversive motives (BIS; unidimensional) and appetitive motives (BAS; comprised of drive, fun-seeking, and reward subscales). The Self-Assessment Manikin picture rating system (SAM; Bradley & Lang, 1994) includes two nine-point scales for rating valence (i.e., displeasure/pleasure) and arousal (i.e., calm/excitement) experienced at the moment. This method has shown strong validity and test–retest reliability in measuring affective reactions (Bradley & Lang, 1994). The participants were also asked to make alcohol craving ratings following images on 1 (no craving or desire) to 9 (intense craving or desire) scale. 2.3. Stimuli 2.3.1. Alcohol stimuli To assess responses to alcohol cues, five photographs from each of four alcohol beverage categories (i.e., beer, wine, hard liquor, and
Table 1 Correlation matrix.
Gender Ethnicity Age Cravinga DAQ AUDIT BIS BASD BASF BASR
α
Mean
SD
– – – .99 .89 .87 .69 .78 .72 .82
– – 32.19 5.23 20.54 12.79 19.28 11.50 11.27 16.08
– – 10.63 2.61 9.35 8.17 3.54 2.51 2.43 3.05
Gender 1 – .06 −.17⁎⁎ −1.0 −.23⁎ .20⁎ .11 −.01 .16⁎⁎
Ethnicity
Age
1 −.36⁎ .66⁎ .52⁎ .43⁎
1 −.44⁎ −.39⁎ −.38⁎
−.13 .17⁎⁎ .15⁎⁎ −.15⁎⁎
Cravinga
DAQ
AUDIT
BIS
BASD
BASF
1 −.11 .07 .15⁎⁎ −.14⁎⁎
1 .13 −.001 .27⁎
1 .56⁎ .64⁎
1
BASR
1
.01 −.13 −.17⁎⁎
.75⁎ .61⁎ −.08 .24⁎ .26⁎
.61⁎ −.03 .28⁎ .36⁎
.07
−.02
.06
1
.47⁎
1
Note. DAQ = Desires for Alcohol Questionnaire, AUDIT = Alcohol Use Disorders Identification Test, BIS = Behavioral Inhibition System, BASD = Behavioral Activation System—Drive, BASF = Behavioral Activation System—Fun-seeking, BASR = Behavioral Activation Scale—Reward. Gender: women = 0, men = 1. Ethnicity: White (non-Hispanic) = 0; non-White = 1. a Craving for alcohol following alcohol cues. ⁎ p b .01. ⁎⁎ p b .05.
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D.E. Lovett et al. / Addictive Behaviors 48 (2015) 58–61
mixed drinks) were created. The photographs were reduced to 800 × 600 resolution or its transposed equivalent to be consistent with the IAPS photographs (Lang et al., 2008). All photographs were taken within a simulated bar setting with a neutral, simple background and with focus on the alcoholic beverage. Five variations of each beverage type were presented (e.g., different shades of beer; red, white, and rosé wines).
ratings were higher for alcohol cues compared to neutral and negative cues (see Table 2). Craving ratings following alcohol cues were higher compared to positive cues, while valence and arousal alcohol cue ratings were lower compared to positive cues. Further, alcohol cue ratings were not correlated with behavioral inhibition (see Table 1).
2.3.2. Normative stimuli To assess responses to standardized positive, negative, and neutral affective cues, 12 IAPS pictures were selected from the positive (e.g., couples embracing, wealth, adventure; #4652, 4658, 4659, 4660, 4670, 4676, 4695, 7330, 8502, 8510, 8030, and 8200), negative (e.g., snakes, bears, threat; #1050, 1120, 1300, 1321, 1525, 1931, 6230, 6260, 6244, 6250, 6300, and 6510), and neutral (e.g., hairdryer, lamp, clock; #7000, 7010, 7020, 7030, 7041, 7050, 7052, 7055, 7175, 7190, 7217, and 7235) categories (Lang et al., 2008).
As shown in Table 1, alcohol cue craving was negatively correlated with age and was significantly higher among men (M = 5.49, SD = 2.58) and non-White participants (M = 6.51, SD = 1.92) than for women (M = 4.49, SD = 2.63) and White (non-Hispanic) participants (M = 2.91, SD = 2.07).
3. Results 3.1. Factor structure and internal consistency First, we conducted an obliquely-rotated principal component analysis (PCA) to test the factor structure of the alcohol craving ratings from the 20 alcohol cues. The PCA revealed a single factor using Horn's (1965) parallel analysis (Eigenvalue = 16.63) which explained 83.14% of the variance. All items had salient factor loadings on the factor (range = .85–.94). The internal consistency for the retained factor was excellent (α = .99). 3.2. Convergent and incremental validity As shown in Table 1, convergent validity was supported by positive correlations between alcohol craving ratings and theoretically-related constructs of general alcohol craving, hazardous alcohol use, and the drive and fun-seeking (but not reward) behavioral activation scales (Franken & Muris, 2006; Grüsser et al., 2000; Pulido et al., 2008). Incremental validity was supported in that craving ratings following alcohol cues were positively correlated with hazardous alcohol use after controlling for general alcohol craving, behavioral activation facets, and craving ratings following neutral cues (i.e., cue-specific craving response), rp(190) = .21, p b .01. Further, alcohol craving ratings were positively correlated with general alcohol craving, controlling for hazardous alcohol use, behavioral activation facets, and neutral cue craving ratings, rp(190) = .51, p b .001. 3.3. Discriminant validity Paired-sample t-tests examining the effect of picture type (alcohol vs. neutral, alcohol vs. negative, and alcohol vs. positive) on valence, arousal, and craving ratings following cue exposure revealed that all
3.4. Demographics
4. Discussion The present study expanded upon previous alcohol cue standardization studies (Billieux et al., 2011; Carter, 2010; Pulido et al., 2008) by (1) reducing the likelihood of extraneous factors influencing reactivity by having the beverage as the focus of the cues; (2) including related measures to improve assessment of validity and reliability; (3) assessing subjective craving alongside measures of valence and arousal following each cue; and (4) by including four commonly consumed beverages (beer, wine, liquor, and mixed drinks) in the alcohol cue set. Overall, our results provide psychometric support (factorial, convergent, incremental, and discriminant validity; internal consistency) for this alcohol cue set to measure alcohol craving among non-dependent alcohol users in a cue reactivity paradigm. Supporting the convergent validity, large positive effects were observed between alcohol cue craving ratings and theoretically-relevant measures such as general alcohol craving and past-year hazardous alcohol use. These effects remained after controlling for neutral cue craving and other related constructs, suggesting that the effects were specific to our alcohol cues. As expected, smaller effects were found between craving ratings following alcohol cues behavioral drive and fun-seeking behavior. This pattern was expected as general craving for alcohol and hazardous alcohol use have been shown to have large effects on alcohol cue craving ratings (Carter, 2010; White & Staiger, 1991), whereas behavioral drive (Franken, 2002) and fun-seeking (Franken & Muris, 2006; Yen, Ko, Yen, Chen, & Chen, 2009) have been shown to have weaker but significant associations with alcohol craving or alcohol-related variables. Though surprising that the reward component of behavioral activation was unrelated to alcohol cue craving, this may be related to findings that reward responsiveness is only correlated with DAQ items that reflect the expected relief from negative states through drinking alcohol (Franken, 2002). Supporting discriminant validity, behavioral inhibition was not related to alcohol cue craving and alcohol craving ratings assessed following the alcohol cues were significantly higher than those following neutral, negative, and positive cues. Craving ratings following alcohol cues should be unrelated to aversive motivational states
Table 2 Subjective cue ratings by cue type. Alcohol
Positive
Neutral
Negative
Valence
6.34 (SD = 1.53) a = .97
6.73 (SD = 1.38) a = .91 t(194) = 3.95⁎
4.53 (SD = .52) a = .93 t(194) = 12.79⁎
3.24 (SD = 1.82) a = .96 t(194) = 19.67⁎
Arousal
5.41 (SD = 2.27) a = .99
Craving
5.23 (SD = 2.63) a = .99
6.17 (SD = 1.84) a = .94 t(194) = 6.06⁎ 4.59 (SD = 2.63) a = .97 t(194) = 5.47⁎
3.35 (SD = 1.59) a = .94 t(194) = 14.17⁎ 2.83 (SD = 1.72) a = .95 t(194) = 16.21⁎
4.05 (SD = 2.10) a = .96 t(194) = 5.91⁎ 2.48 (SD = 1.79) a = .96 t(194) = 15.76⁎
Note. Rating scales ranged from 1 to 9 and were averaged within photo and rating type. ⁎ p b .001 (ratings significantly different compared to respective rating following alcohol cues).
D.E. Lovett et al. / Addictive Behaviors 48 (2015) 58–61
(e.g., fear, anxiety, sadness), and should instead be associated with appetitive motivational states (e.g., subjective craving) due to incentivemotivational properties of the alcohol cues (Carter, 2010; Drobes et al., 2009; Franken & Muris, 2006). 5. Limitations and future directions First, it is possible that the alcohol craving ratings did not capture the multidimensional model of alcohol craving proposed to be ideal in cue reactivity studies (Connolly, Coffey, Baschnagel, Drobes, & Saladin, 2009; Schulze & Jones, 2000). Secondly, while alcohol cue craving ratings across age and gender were consistent with alcohol use trends, the ethnic differences are not clearly supported by previous literature (Ham & Hope, 2003). Thus, it remains unclear what the implications are for using these alcohol cues across different ethnic groups. Thirdly, future studies may benefit from recruiting participants based on drink type preference to fully understand the effects of preference on ratings of craving. 6. Conclusions This is the only known alcohol cue standardization study to validate a set of alcohol cues including images of four types of alcoholic beverages that were created with the beverage as the sole focus in each alcohol cue. As no previous study has examined the factor structure, reliability, and validity of a set of alcohol cues for the purpose of measuring alcohol craving, the implications for such findings appear to be potentially far-reaching given the widespread use of photographic alcohol stimuli in research studies. Assessing reactivity using this alcohol cue set may facilitate a greater understanding of the affective processes associated with alcohol use and allow for more targeted interventions for alcohol-related problems. Role of funding sources Funding for this study was provided, in part by, a Marie Wilson Howells student grant 1211.01S, an internal departmental grant awarded to graduate students in the Department of Psychological Science at the University of Arkansas. Additionally preparation of the manuscript was provided, in part by, a grant from ABMRF/The Foundation for Alcohol Research awarded to the second author. Neither the Marie Wilson Howells student grant nor the ABMRF grant had any role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Contributors Mr. Lovett was the lead investigator and was involved in all facets of the study and manuscript preparation. Dr. Ham co-conceptualized and advised the study design. Dr. Veilleux made contributions to the study design and provided input regarding the full draft of the manuscript. Mr. Lovett and Dr. Ham planned the statistical analyses and Mr. Lovett conducted the statistical analysis. Drs. Ham and Veilleux consulted in the development of the literature review. Mr. Lovett wrote the first draft of the manuscript. All authors contributed to, edited, and have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest. Acknowledgments The authors wish to thank Dr. Bill Levine for his input related to the development and refinement of the alcohol cue photograph set.
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Contents lists available at ScienceDirect
Addictive Behaviors
Short Communication
Psychometric evaluation of a standardized set of alcohol cue photographs to assess craving David E. Lovett ⁎, Lindsay S. Ham, Jennifer C. Veilleux University of Arkansas, USA
H I G H L I G H T S • • • •
This study presents psychometric properties of a new set of alcohol photo cues. Images of alcohol standardized with beverage as the primary focus of each image Alcohol cue craving ratings formed one internally consistent factor. Findings supported convergent, incremental, and discriminant validity of cues.
a r t i c l e
i n f o
Available online 8 May 2015 Keywords: Alcohol Craving Cue Photographs Standardized Reactivity
a b s t r a c t Introduction: Research using alcohol-related visual stimuli has been limited due to a lack of published studies examining the psychometric properties of alcohol cues. The primary aim of the current study was to examine the factor structure, validity, and reliability of craving ratings following exposure to alcohol cues (including beer, wine, hard liquor, and mixed drinks) in an alcohol cue-reactivity paradigm. Methods: U.S. adults ages 21-69 [N = 195; Mage = 32.19, SD = 10.63; 74.4% male; 56.4% Asian/Pacific Islander, 34.9% White (non-Hispanic), 4.6% Other, 2.0% Hispanic/Latino, 1.5% Native American/Alaskan Native, and 0.5% African-American] completed questionnaires and provided craving, arousal, and valence ratings following alcohol, positive, negative and neutral cues in a web-based study. Results: The alcohol craving ratings following alcohol cues formed one internally consistent factor. Convergent and incremental validity was supported as alcohol cue craving ratings were positively correlated with general craving, past-year hazardous alcohol use, and behavioral activation facets, even while controlling for neutral cue craving ratings and other related variables. Alcohol craving was significantly higher following alcohol cues compared to neutral cues and unrelated to behavioral inhibition, supporting discriminant validity. Conclusions: These findings provide support that the alcohol cues we developed are reliable and valid stimuli for the use in alcohol cue reactivity paradigms. Future research assessing alcohol cue reactivity using this validated photographic cue set may facilitate a greater understanding of the affective processes associated with alcohol use and allow for more targeted behavioral change interventions for alcohol-related problems. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Alcohol craving or one's “desire or urge to drink,” is associated with severity of alcohol use problems and impacts a person's approach or avoidance of alcohol consumption (Kramer et al., 2010; Wiers et al., 2007). While researchers have examined reactions to alcohol cues, the lack of a validated alcohol cue set to assess alcohol craving has hindered the interpretations that can be drawn across studies. Alcohol cue reactivity studies examining pictorial stimuli have included alcoholrelated cues sourced from the following: (1) standardized picture sets ⁎ Corresponding author at: Department of Psychological Science, University of Arkansas, Fayetteville, AR 72701, USA. Tel.: +1 479 575 4256. E-mail address: [email protected] (D.E. Lovett).
http://dx.doi.org/10.1016/j.addbeh.2015.05.002 0306-4603/© 2015 Elsevier Ltd. All rights reserved.
that were not developed with the intention of assessing craving (e.g., Normative Affective Picture System [NAPS; Stritzke, Breiner, Curtin, & Lang, 2004] and International Affective Picture System [IAPS; Lang, Bradley, & Cuthbert, 2008]; Drobes, Carter, & Goldman, 2009), (2) internet and stock photography (e.g., Carter, 2010; Drobes et al., 2009; Pulido, Brown, Cummins, Paulus, & Tapert, 2010), or (3) researcher-created photographs (e.g., Billieux et al., 2011). Some of these studies used alcohol cues without supporting psychometric evidence (Carter, 2010; Drobes et al., 2009; Grüsser, Heinz, & Flor, 2000). Other researchers provided some psychometric data related to alcohol cues; however, aspects related to the content presented within the photographs are problematic and could be improved to provide a more precise and comprehensive examination of alcohol cue reactivity (Billieux et al., 2011; Carter, 2010; Lee, Namkoong, Lee, An, & Lee, 2006).
D.E. Lovett et al. / Addictive Behaviors 48 (2015) 58–61
Of the available work to date focused on developing and evaluating a set of standardized alcohol photo cues (e.g., Billieux et al., 2011; Lee et al., 2006; Pulido et al., 2010), there remain several limitations. For example, the content of many photo cues used also include social cues, branding and labels used in advertising, and other environmental stimuli (Billieux et al., 2011; Lee et al., 2006; Pulido et al., 2010) that while potentially enhancing ecological validity, pose threats to internal validity. Further, many studies used idiographic stimuli based on each participant's preferred beverage (Coffey, Saladin, Libet, Drobes, & Dansky, 1999; Payne et al., 1992; Pomerleau, Fertig, Baker, & Cooney, 1983; Schulze & Jones, 2000) without first fully understanding the effect of personalized cues compared to standardized cues. Finally, there has been little attention to assessing craving following alcohol cue presentation, even with the repeated assertion that craving ratings are a necessary component for substance stimuli validation (e.g., nicotine: Carter et al., 2006; alcohol: Carter, 2010). Taken together, there is a lack of empirical work focused on validating a standardized alcohol cue picture set. 1.1. Current study We aimed to evaluate the psychometric properties for a set of alcohol cues for use in non-alcohol dependent samples. The present study expanded upon previous alcohol cue standardization studies (Billieux et al., 2011; Lee et al., 2006; Pulido et al., 2010) by (1) examining a set of alcohol beverage cues that adequately excluded extraneous influences (e.g., advertising, branding, social depictions, gender stereotypes, and inclusion of cigarette smoking); (2) providing a more comprehensive assessment of validity and reliability; (3) adding the measurement of subjective craving alongside valence and arousal following each cue; and (4) including commonly consumed beverages (e.g., beer, wine, liquor, mixed drinks) in the alcohol cue set. We examined factor structure, internal consistency, as well as convergent, incremental, and discriminant validity to evaluate the psychometric properties of the alcohol cues. 2. Method 2.1. Participants and procedures U.S. adults (N = 195) of ages 21–69 [Mage = 32.19, SD = 10.63; 74.4% male; 56.4% Asian or Pacific Islander, 34.9% White (non-Hispanic), 4.6% Other, 2% Hispanic/Latino, 1.5% Native American/Alaskan Native, and 0.5% African-American] were recruited through Mechanical Turk© (MTurk®). Participants reported past 30-day alcohol use, denied past4-hour alcohol use, denied being an alcoholic or abstaining from alcohol,
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and had an MTurk® “quality rating” of ≥ .90. Most participants had a two-year college degree or higher (77.4%) and were employed (82.1%). The participants were directed to Qualtrics® for informed consent, the online study, and debriefing. Upon providing informed consent, the participants completed self-report questionnaires and a cue rating task in which the participants were shown a series of photographs and asked to provide valence, arousal, and craving ratings after each cue. Twenty alcohol cues (five pictures from each of four alcohol beverage categories) and 12 pictures from each of three IAPS categories (positive, negative, neutral) were presented in randomized order. The participants were debriefed and compensated $0.69, based on the average MTurk® rate. 2.2. Measures The Desires for Alcohol Questionnaire (DAQ; Love, James, & Willner, 1998) measured desire to drink, ability to control drinking, anticipation of positive drinking outcomes, and anticipation of relief from negative affect or alcohol withdrawal. The DAQ has demonstrated concurrent validity and reliability among individuals with and without an alcohol use disorder (Kramer et al., 2010). See Table 1 for means, standard deviations, and Cronbach's alphas for multi-item self-report measures. The Alcohol Use Disorder Identification Test (AUDIT; Babor, HigginsBiddle, Saunders, & Monteiro, 2001) is a well-established measure of past-year hazardous alcohol use (i.e., alcohol use quantity/frequency, dependence symptoms, and negative consequences). The Behavioral Inhibition System/Behavioral Activation System (BIS/BAS; Carver & White, 1994) was used to measure individual differences in the sensitivity and regulation of both aversive motives (BIS; unidimensional) and appetitive motives (BAS; comprised of drive, fun-seeking, and reward subscales). The Self-Assessment Manikin picture rating system (SAM; Bradley & Lang, 1994) includes two nine-point scales for rating valence (i.e., displeasure/pleasure) and arousal (i.e., calm/excitement) experienced at the moment. This method has shown strong validity and test–retest reliability in measuring affective reactions (Bradley & Lang, 1994). The participants were also asked to make alcohol craving ratings following images on 1 (no craving or desire) to 9 (intense craving or desire) scale. 2.3. Stimuli 2.3.1. Alcohol stimuli To assess responses to alcohol cues, five photographs from each of four alcohol beverage categories (i.e., beer, wine, hard liquor, and
Table 1 Correlation matrix.
Gender Ethnicity Age Cravinga DAQ AUDIT BIS BASD BASF BASR
α
Mean
SD
– – – .99 .89 .87 .69 .78 .72 .82
– – 32.19 5.23 20.54 12.79 19.28 11.50 11.27 16.08
– – 10.63 2.61 9.35 8.17 3.54 2.51 2.43 3.05
Gender 1 – .06 −.17⁎⁎ −1.0 −.23⁎ .20⁎ .11 −.01 .16⁎⁎
Ethnicity
Age
1 −.36⁎ .66⁎ .52⁎ .43⁎
1 −.44⁎ −.39⁎ −.38⁎
−.13 .17⁎⁎ .15⁎⁎ −.15⁎⁎
Cravinga
DAQ
AUDIT
BIS
BASD
BASF
1 −.11 .07 .15⁎⁎ −.14⁎⁎
1 .13 −.001 .27⁎
1 .56⁎ .64⁎
1
BASR
1
.01 −.13 −.17⁎⁎
.75⁎ .61⁎ −.08 .24⁎ .26⁎
.61⁎ −.03 .28⁎ .36⁎
.07
−.02
.06
1
.47⁎
1
Note. DAQ = Desires for Alcohol Questionnaire, AUDIT = Alcohol Use Disorders Identification Test, BIS = Behavioral Inhibition System, BASD = Behavioral Activation System—Drive, BASF = Behavioral Activation System—Fun-seeking, BASR = Behavioral Activation Scale—Reward. Gender: women = 0, men = 1. Ethnicity: White (non-Hispanic) = 0; non-White = 1. a Craving for alcohol following alcohol cues. ⁎ p b .01. ⁎⁎ p b .05.
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mixed drinks) were created. The photographs were reduced to 800 × 600 resolution or its transposed equivalent to be consistent with the IAPS photographs (Lang et al., 2008). All photographs were taken within a simulated bar setting with a neutral, simple background and with focus on the alcoholic beverage. Five variations of each beverage type were presented (e.g., different shades of beer; red, white, and rosé wines).
ratings were higher for alcohol cues compared to neutral and negative cues (see Table 2). Craving ratings following alcohol cues were higher compared to positive cues, while valence and arousal alcohol cue ratings were lower compared to positive cues. Further, alcohol cue ratings were not correlated with behavioral inhibition (see Table 1).
2.3.2. Normative stimuli To assess responses to standardized positive, negative, and neutral affective cues, 12 IAPS pictures were selected from the positive (e.g., couples embracing, wealth, adventure; #4652, 4658, 4659, 4660, 4670, 4676, 4695, 7330, 8502, 8510, 8030, and 8200), negative (e.g., snakes, bears, threat; #1050, 1120, 1300, 1321, 1525, 1931, 6230, 6260, 6244, 6250, 6300, and 6510), and neutral (e.g., hairdryer, lamp, clock; #7000, 7010, 7020, 7030, 7041, 7050, 7052, 7055, 7175, 7190, 7217, and 7235) categories (Lang et al., 2008).
As shown in Table 1, alcohol cue craving was negatively correlated with age and was significantly higher among men (M = 5.49, SD = 2.58) and non-White participants (M = 6.51, SD = 1.92) than for women (M = 4.49, SD = 2.63) and White (non-Hispanic) participants (M = 2.91, SD = 2.07).
3. Results 3.1. Factor structure and internal consistency First, we conducted an obliquely-rotated principal component analysis (PCA) to test the factor structure of the alcohol craving ratings from the 20 alcohol cues. The PCA revealed a single factor using Horn's (1965) parallel analysis (Eigenvalue = 16.63) which explained 83.14% of the variance. All items had salient factor loadings on the factor (range = .85–.94). The internal consistency for the retained factor was excellent (α = .99). 3.2. Convergent and incremental validity As shown in Table 1, convergent validity was supported by positive correlations between alcohol craving ratings and theoretically-related constructs of general alcohol craving, hazardous alcohol use, and the drive and fun-seeking (but not reward) behavioral activation scales (Franken & Muris, 2006; Grüsser et al., 2000; Pulido et al., 2008). Incremental validity was supported in that craving ratings following alcohol cues were positively correlated with hazardous alcohol use after controlling for general alcohol craving, behavioral activation facets, and craving ratings following neutral cues (i.e., cue-specific craving response), rp(190) = .21, p b .01. Further, alcohol craving ratings were positively correlated with general alcohol craving, controlling for hazardous alcohol use, behavioral activation facets, and neutral cue craving ratings, rp(190) = .51, p b .001. 3.3. Discriminant validity Paired-sample t-tests examining the effect of picture type (alcohol vs. neutral, alcohol vs. negative, and alcohol vs. positive) on valence, arousal, and craving ratings following cue exposure revealed that all
3.4. Demographics
4. Discussion The present study expanded upon previous alcohol cue standardization studies (Billieux et al., 2011; Carter, 2010; Pulido et al., 2008) by (1) reducing the likelihood of extraneous factors influencing reactivity by having the beverage as the focus of the cues; (2) including related measures to improve assessment of validity and reliability; (3) assessing subjective craving alongside measures of valence and arousal following each cue; and (4) by including four commonly consumed beverages (beer, wine, liquor, and mixed drinks) in the alcohol cue set. Overall, our results provide psychometric support (factorial, convergent, incremental, and discriminant validity; internal consistency) for this alcohol cue set to measure alcohol craving among non-dependent alcohol users in a cue reactivity paradigm. Supporting the convergent validity, large positive effects were observed between alcohol cue craving ratings and theoretically-relevant measures such as general alcohol craving and past-year hazardous alcohol use. These effects remained after controlling for neutral cue craving and other related constructs, suggesting that the effects were specific to our alcohol cues. As expected, smaller effects were found between craving ratings following alcohol cues behavioral drive and fun-seeking behavior. This pattern was expected as general craving for alcohol and hazardous alcohol use have been shown to have large effects on alcohol cue craving ratings (Carter, 2010; White & Staiger, 1991), whereas behavioral drive (Franken, 2002) and fun-seeking (Franken & Muris, 2006; Yen, Ko, Yen, Chen, & Chen, 2009) have been shown to have weaker but significant associations with alcohol craving or alcohol-related variables. Though surprising that the reward component of behavioral activation was unrelated to alcohol cue craving, this may be related to findings that reward responsiveness is only correlated with DAQ items that reflect the expected relief from negative states through drinking alcohol (Franken, 2002). Supporting discriminant validity, behavioral inhibition was not related to alcohol cue craving and alcohol craving ratings assessed following the alcohol cues were significantly higher than those following neutral, negative, and positive cues. Craving ratings following alcohol cues should be unrelated to aversive motivational states
Table 2 Subjective cue ratings by cue type. Alcohol
Positive
Neutral
Negative
Valence
6.34 (SD = 1.53) a = .97
6.73 (SD = 1.38) a = .91 t(194) = 3.95⁎
4.53 (SD = .52) a = .93 t(194) = 12.79⁎
3.24 (SD = 1.82) a = .96 t(194) = 19.67⁎
Arousal
5.41 (SD = 2.27) a = .99
Craving
5.23 (SD = 2.63) a = .99
6.17 (SD = 1.84) a = .94 t(194) = 6.06⁎ 4.59 (SD = 2.63) a = .97 t(194) = 5.47⁎
3.35 (SD = 1.59) a = .94 t(194) = 14.17⁎ 2.83 (SD = 1.72) a = .95 t(194) = 16.21⁎
4.05 (SD = 2.10) a = .96 t(194) = 5.91⁎ 2.48 (SD = 1.79) a = .96 t(194) = 15.76⁎
Note. Rating scales ranged from 1 to 9 and were averaged within photo and rating type. ⁎ p b .001 (ratings significantly different compared to respective rating following alcohol cues).
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(e.g., fear, anxiety, sadness), and should instead be associated with appetitive motivational states (e.g., subjective craving) due to incentivemotivational properties of the alcohol cues (Carter, 2010; Drobes et al., 2009; Franken & Muris, 2006). 5. Limitations and future directions First, it is possible that the alcohol craving ratings did not capture the multidimensional model of alcohol craving proposed to be ideal in cue reactivity studies (Connolly, Coffey, Baschnagel, Drobes, & Saladin, 2009; Schulze & Jones, 2000). Secondly, while alcohol cue craving ratings across age and gender were consistent with alcohol use trends, the ethnic differences are not clearly supported by previous literature (Ham & Hope, 2003). Thus, it remains unclear what the implications are for using these alcohol cues across different ethnic groups. Thirdly, future studies may benefit from recruiting participants based on drink type preference to fully understand the effects of preference on ratings of craving. 6. Conclusions This is the only known alcohol cue standardization study to validate a set of alcohol cues including images of four types of alcoholic beverages that were created with the beverage as the sole focus in each alcohol cue. As no previous study has examined the factor structure, reliability, and validity of a set of alcohol cues for the purpose of measuring alcohol craving, the implications for such findings appear to be potentially far-reaching given the widespread use of photographic alcohol stimuli in research studies. Assessing reactivity using this alcohol cue set may facilitate a greater understanding of the affective processes associated with alcohol use and allow for more targeted interventions for alcohol-related problems. Role of funding sources Funding for this study was provided, in part by, a Marie Wilson Howells student grant 1211.01S, an internal departmental grant awarded to graduate students in the Department of Psychological Science at the University of Arkansas. Additionally preparation of the manuscript was provided, in part by, a grant from ABMRF/The Foundation for Alcohol Research awarded to the second author. Neither the Marie Wilson Howells student grant nor the ABMRF grant had any role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Contributors Mr. Lovett was the lead investigator and was involved in all facets of the study and manuscript preparation. Dr. Ham co-conceptualized and advised the study design. Dr. Veilleux made contributions to the study design and provided input regarding the full draft of the manuscript. Mr. Lovett and Dr. Ham planned the statistical analyses and Mr. Lovett conducted the statistical analysis. Drs. Ham and Veilleux consulted in the development of the literature review. Mr. Lovett wrote the first draft of the manuscript. All authors contributed to, edited, and have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest. Acknowledgments The authors wish to thank Dr. Bill Levine for his input related to the development and refinement of the alcohol cue photograph set.
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