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1.  Dual Process Interaction Model of HIV-Risk Behaviors Among Drug Offenders 
AIDS and behavior  2013;17(3):914-925.
This study evaluated dual process interaction models of HIV-risk behavior among drug offenders. A dual process approach suggests that decisions to engage in appetitive behaviors result from a dynamic interplay between a relatively automatic associative system and an executive control system. One synergistic type of interplay suggests that executive functions may dampen or block effects of spontaneously activated associations. Consistent with this model, latent variable interaction analyses revealed that drug offenders scoring higher in affective decision making were relatively protected from predictive effects of spontaneous sex associations promoting risky sex. Among drug offenders with lower levels of affective decision making ability, spontaneous sexually-related associations more strongly predicted risky sex (lack of condom use and greater number of sex partners). These findings help elucidate associative and control process effects on appetitive behaviors and are important for explaining why some individuals engage in risky sex, while others are relatively protected.
doi:10.1007/s10461-012-0140-2
PMCID: PMC3435485  PMID: 22331391
Dual processes; Implicit associations; Decision making; HIV risk; Condom use
2.  Deliberative and spontaneous cognitive processes associated with HIV risk behavior 
Journal of behavioral medicine  2012;36(1):95-107.
Dual process models of decision-making suggest that behavior is mediated by a spontaneous behavior selection process or by a more deliberative evaluation of behavioral options. We examined whether the deliberative system moderates the influence of spontaneous cognition on HIV-risk behaviors. A measure of spontaneous sex-related associations (word association), a measure of deliberative working memory capacity (operation span), and two measures of sexual behavior (condom use and multiple partners) were assessed in a cross-sectional study among 490 adult drug offenders. Significant effects were observed among men but not among women in two latent interaction models. In a novel finding, the accessibility of spontaneous safe sex-related associations was significantly more predictive of condom use among men with higher working memory capacity than among men with lower capacity. These results have implications for the design of interventions to promote safe sex practices.
doi:10.1007/s10865-012-9404-6
PMCID: PMC3465482  PMID: 22331437
Dual process; Implicit cognition; HIV risk; Decision making; Working memory capacity
3.  Exposure to Alcohol Advertisements and Teenage Alcohol-Related Problems 
Pediatrics  2013;131(2):e369-e379.
OBJECTIVE:
This study used prospective data to test the hypothesis that exposure to alcohol advertising contributes to an increase in underage drinking and that an increase in underage drinking then leads to problems associated with drinking alcohol.
METHODS:
A total of 3890 students were surveyed once per year across 4 years from the 7th through the 10th grades. Assessments included several measures of exposure to alcohol advertising, alcohol use, problems related to alcohol use, and a range of covariates, such as age, drinking by peers, drinking by close adults, playing sports, general TV watching, acculturation, parents’ jobs, and parents’ education.
RESULTS:
Structural equation modeling of alcohol consumption showed that exposure to alcohol ads and/or liking of those ads in seventh grade were predictive of the latent growth factors for alcohol use (past 30 days and past 6 months) after controlling for covariates. In addition, there was a significant total effect for boys and a significant mediated effect for girls of exposure to alcohol ads and liking of those ads in 7th grade through latent growth factors for alcohol use on alcohol-related problems in 10th grade.
CONCLUSIONS:
Younger adolescents appear to be susceptible to the persuasive messages contained in alcohol commercials broadcast on TV, which sometimes results in a positive affective reaction to the ads. Alcohol ad exposure and the affective reaction to those ads influence some youth to drink more and experience drinking-related problems later in adolescence.
doi:10.1542/peds.2012-1480
PMCID: PMC3557408  PMID: 23359585
alcohol advertising; alcohol drinking; adolescent; statistical model
4.  Affective decision-making deficits, linked to a dysfunctional ventromedial prefrontal cortex, revealed in 10th-grade Chinese adolescent smokers 
This study addressed the question of whether poor decision making would be associated with adolescent past 7-day smoking. We conducted a cross-sectional study of 208 10th-grade adolescents in Chengdu City, China. We used the Iowa Gambling Task (IGT) to assess decision-making, and the Self-ordered Pointing Task (SOPT) to assess working memory capacity. Paper and pencil questionnaires assessed the school academic performance (SAP) and smoking variables. The results showed that a significantly higher proportion of past 7-day smokers (91.7%) were susceptible to future smoking and cigarette offers from best friends compared to other levels of smokers (never, ever and past 30-day smokers). Consistent with these behavioral data, the neuropsychological assessments revealed that relative to never smokers, past 7-day adolescent smokers (but not ever smokers or past 30-day smokers) demonstrated significantly lower scores on the IGT. Moreover, a higher proportion of past 7-day smokers (91.7%) performed poorly (no more than an overall net score of 10) on the IGT than nonsmokers and irregular (ever or past 30-day) smokers (about 65.3%). There were no differences on working memory performance for smokers (at any level) compared to never smokers after adjusting for school-type. In addition, logistic regression showed that the IGT significantly predicted past 7-day smoking after controlling for the working memory, school academic performance and demographic variables. These results suggest that poor affective decision making might predispose some adolescents to smoking in the future or in the social situations where their peers are smoking. Intervention targeting affective decision making might hold promise for reducing adolescents’ risks for substance use.
doi:10.1080/14622200802097530
PMCID: PMC2621100  PMID: 18584472
5.  Social network influences of alcohol and marijuana cognitive associations 
Addictive Behaviors  2011;36(12):1305-1308.
Decision-making is a social process whereby behaviors are often driven by social influences and social consequences. Research shows that social context also plays an integral role in decision-making processes. In particular, evidence suggests that implicit or non-conscious cognitions are linked to social information in memory and that implicit attitudes can be communicated and assimilated between people on an unconscious level. This study assesses social contagion of implicit cognitions regarding alcohol and marijuana among high school friend networks. Data are from an evidence-based drug education program delivered by either a health educator or by nominated class leaders over a 3-month period. Implicit attitudes were found to be susceptible to social influences, particularly for alcohol. Surprisingly, social contagion was stronger for cognitions than for behaviors. In addition, results support prior research that has found that implicit attitudes are not entirely stable and may be more susceptible to change than are behaviors. Public health initiatives to engender behavioral change could be facilitated by targeting flexible cognitive associations within existing social network structures.
doi:10.1016/j.addbeh.2011.07.008
PMCID: PMC3343735  PMID: 21872402
Social Network Analysis; Implicit Cognition; Alcohol; Marijuana; Social Contagion; Intervention
6.  Affective decision-making deficits, linked to a dysfunctional ventromedial prefrontal cortex, revealed in 10th grade Chinese adolescent binge drinkers 
Neuropsychologia  2007;46(2):714-726.
The primary aim of this study was to test the hypothesis that adolescent binge drinkers, but not lighter drinkers, would show signs of impairment on tasks of affective decision-making as measured by the Iowa Gambling Test (IGT), when compared to adolescents who never drank.
We tested 207 10th grade adolescents in Chengdu City, China, using two versions of the IGT, the original and a variant, in which the reward/punishment contingencies were reversed. This enables one to distinguish among different possibilities of impaired decision-making, such as insensitivity to long-term consequences, or hypersensitivity to reward. Furthermore, we tested working memory capacity using the Self-ordered Pointing Test (SOPT). Paper and pencil questionnaires were used to assess drinking behaviors and school academic performance.
Results indicated that relative to never-drinkers, adolescent binge drinkers, but not other (ever, past 30-day) drinkers, showed significantly lower net scores on the original version of the IGT especially in the latter trials. Furthermore, the profiles of behavioral performance from the original and variant versions of the IGT were consistent with a decision-making impairment attributed to hypersensitivity to reward. In addition, working memory and school academic performance revealed no differences between drinkers (at all levels) and never-drinkers. Logistic regression analysis showed that after controlling for demographic variables, working memory, and school academic performance, the IGT significantly predicted binge-drinking.
These findings suggest that a “myopia” for future consequences linked to hypersensitivity to reward is a key characteristic of adolescents with binge-drinking behavior, and that underlying neural mechanisms for this “myopia” for future consequences may serve as a predisposing factor that renders some adolescents more susceptible to future addictive behaviors.
doi:10.1016/j.neuropsychologia.2007.09.012
PMCID: PMC3498846  PMID: 17996909
Executive function; Affective control; Reward; Working memory; Adolescent drinking; Iowa Gambling Test
7.  Are Alcohol Expectancies Associations? Comment on Moss and Albery (2009) 
Psychological bulletin  2010;136(1):12-20.
A. C. Moss and I. P. Albery (2009) presented a dual-process model of the alcohol-behavior link, integrating alcohol expectancy and alcohol myopia theory. Their integrative theory rests on a number of assumptions including, first, that alcohol expectancies are associations that can be activated automatically by an alcohol-relevant context, and second, that alcohol selectively reduces propositional reasoning. As a result, behavior comes under the control of associative processes after alcohol consumption. We agree with the second but not with the first assumption, based on theoretical and empirical arguments. Although in some cases expectancies may involve a simple association, they are propositional in nature. We demonstrate that this assertion is supported by existing literature cited in Moss and Albery. Moreover, six recent studies consistently demonstrated that under circumstances where executive control is impaired (either as a stable individual difference or under the acute influence of alcohol), associative processes, over and above expectancies, predict alcohol-related behavior. Taken together, the evidence strongly suggests a fundamental distinction between expectancies and associations in memory: effects of propositional expectancies and executive functions are impaired under the acute influence of alcohol but memory associations are not. This difference in perspective not only has theoretical implications, but also leads to different predictions regarding acute alcohol effects in society.
doi:10.1037/a0017769
PMCID: PMC3468318  PMID: 20063922
Dual-Process Theories; Automatic and Controlled Processes; Acute Alcohol Effects
8.  Implicit Cognition and Addiction: A Tool for Explaining Paradoxical Behavior 
Research on implicit cognition and addiction has expanded greatly during the past decade. This research area provides new ways to understand why people engage in behaviors that they know are harmful or counterproductive in the long run. Implicit cognition takes a different view from traditional cognitive approaches to addiction by assuming that behavior is often not a result of a reflective decision that takes into account the pros and cons known by the individual. Instead of a cognitive algebra integrating many cognitions relevant to choice, implicit cognition assumes that the influential cognitions are the ones that are spontaneously activated during critical decision points. This selective review highlights many of the consistent findings supporting predictive effects of implicit cognition on substance use and abuse in adolescents and adults; reveals a recent integration with dual-process models; outlines the rapid evolution of different measurement tools; and introduces new routes for intervention.
doi:10.1146/annurev.clinpsy.121208.131444
PMCID: PMC3423976  PMID: 20192786
implicit association; treatment; prevention; adolescents; college students; health behavior
9.  Context Effects and False Memory for Alcohol Words in Adolescents 
Addictive behaviors  2008;34(3):327-330.
This study assessed incidental recognition of Alcohol and Neutral words in adolescents who encoded the words under distraction. Participants were 171 (81 male) 10th grade students, ages 14–16 (M = 15.1) years. Testing was conducted by telephone: Participants listened to a list containing Alcohol and Neutral (Experimental – Group E, n = 92) or only Neutral (Control – Group C, n = 79) words, while counting backwards from 200 by two’s. Recognition was tested immediately thereafter. Group C exhibited higher false recognition of Neutral than Alcohol items, whereas Group E displayed equivalent false rates for both word types. The reported number of alcohol TV ads seen in the past week predicted higher false recognition of Neutral words in Group C and of Alcohol words in Group E. False memory for Alcohol words in Group E was greater in males and high anxiety sensitive participants. These context-dependent biases may contribute to exaggerations in perceived drinking norms previously found to predict alcohol misuse in young drinkers.
doi:10.1016/j.addbeh.2008.11.002
PMCID: PMC3172138  PMID: 19081200
alcohol; adolescents; false memory; recognition; advertising; context
10.  Brief Intervention for Substance Use among At-Risk Adolescents: A Pilot Study 
This pilot study demonstrates that it is feasible to administer brief individualized interventions on alternative high school campuses to students who are at risk of substance abuse. Students actively participated in brief motivational interviews and showed some improvement in five of nine outcomes at three-month follow-ups.
doi:10.1016/j.jadohealth.2006.08.008
PMCID: PMC3134418  PMID: 17259065
Substance use; Adolescents; Motivational interviewing; Brief intervention
11.  Impulsivity, Impulsive and Reflective Processes and the Development of Alcohol Use and Misuse in Adolescents and Young Adults 
This paper contrasts dual-process and personality approaches in the prediction of addictive behaviors and related risk behaviors. In dual-process models, behavior is described as the joint outcome of qualitatively different “impulsive” (or associative) and “reflective” processes. There are important individual differences regarding both types of processes, and the relative strength of both in a specific situation is influenced by prior behavior and state variables (e.g., fatigue, alcohol use). From this perspective, a specific behavior (e.g., alcohol misuse) can be predicted by the combined indices of the behavior-related impulsive processes (e.g., associations with alcohol), and reflective processes, including the ability to refrain from a motivationally salient action. Personality approaches have reported that general traits such as impulsivity predict addictive behaviors. Here we contrast these two approaches, with supplementary analyses on four datasets. We hypothesized that trait impulsivity can predict specific risky behaviors, but that its predictive power disappears once specific behavior-related associations, indicators of executive functioning, and their interaction are entered into the equation. In all four studies the observed interaction between specific associations and executive control (EC) was robust: trait impulsivity did not diminish the prediction of alcohol use by the interaction. Trait impulsivity was not always related to alcohol use, and when it was, the predictive power disappeared after entering the interaction between behavior-specific associations and EC in one study, but not in the other. These findings are interpreted in relation to the validity of the measurements used, which leads to a more refined hypothesis.
doi:10.3389/fpsyg.2010.00144
PMCID: PMC3153762  PMID: 21833213
impulsivity; dual process models; addiction; alcohol; executive control; developmental psychopathology; personality
12.  Alcohol, drugs, and condom use among drug offenders: An event-based analysis 
Drug and alcohol dependence  2007;93(1-2):38-42.
Background
Studies of the association between substance use and condom use in specific sexual encounters often do not separate the effects of alcohol and different types of drugs. Because the pharmacological effects and social settings of various substances differ, their effects on unprotected intercourse may vary as well.
Goal
This study examined the relationship between alcohol and drug use and the use of condoms in sexual encounters with casual partners in a high-risk population of drug offenders
Design
Participants in court-ordered drug diversion programs (n=536; 26% female) completed a questionnaire in which they reported on the circumstances of their most recent sexual encounter with a casual partner.
Results
In multivariate logistic models, alcohol use in conjunction with sex was not related to decreased condom use in either men or women. Amphetamines (smoked or injected) were associated with decreased condom use, while cocaine, marijuana, and orally-administered amphetamines were not significantly associated with condom use.
Conclusions
In this high-risk sample, links between substance use and unprotected sex differ with type of drug used.
doi:10.1016/j.drugalcdep.2007.08.012
PMCID: PMC2239344  PMID: 17928167
alcohol; drugs; unprotected sex; condom use
13.  Interactions between implicit and explicit cognition and working memory capacity in the prediction of alcohol use in at-risk adolescents 
Drug and alcohol dependence  2007;94(1-3):116-124.
Dual process models of addiction suggest that the influence of alcohol-related cognition might be dependent on the level of executive functioning. This study investigated if the interaction between implicit and explicit alcohol-related cognitions and working memory capacity predicted alcohol use after one month in at-risk youth. Implicit and explicit alcohol-related cognitions were assessed in 88 Dutch at-risk adolescents ranging in age from 14 to 20 (51 males) with an adapted version of the Implicit Association Test (IAT) and an expectancy questionnaire. Working memory capacity was assessed using the computer-based version of the Self-Ordered Pointing Task (SOPT). Alcohol use and alcohol-related problems were measured at baseline and after one month with self-report questionnaires. The hierarchical regression analysis showed that both the interaction between implicit positive-arousal cognitions and working memory capacity and the interaction between explicit positive-arousal cognitions and working memory capacity predicted unique variance in alcohol use after one month. Implicit positive-arousal cognitions predicted alcohol use after one month more strongly in students with lower levels of working memory capacity, whereas explicit positive-arousal cognitions predicted one-month follow-up alcohol use more strongly in students with higher levels of working memory capacity. This could imply that different intervention methods could be effective for different subgroups of at-risk youth.
doi:10.1016/j.drugalcdep.2007.10.019
PMCID: PMC3413632  PMID: 18155856
implicit cognition; explicit cognition; executive functioning; IAT; adolescence; alcohol use
14.  Influence of Motivational Interviewing on Explicit and Implicit Alcohol-Related Cognition and Alcohol Use in At-Risk Adolescents 
Both implicit and explicit cognitions play an important role in the development of addictive behavior. This study investigated the influence of a single-session motivational interview (MI) on implicit and explicit alcohol-related cognition and whether this intervention was successful in consequently decreasing alcohol use in at-risk adolescents. Implicit and explicit alcohol-related cognitions were assessed at pretest and one month posttest in 125 Dutch at-risk adolescents ranging in age from 15 to 23 (51 males) with adapted versions of the Implicit Association Test (IAT) and an expectancy questionnaire. Motivation to change, alcohol use and alcohol-related problems were measured with self-report questionnaires, at pretest, at posttest after one month, and at the six-month follow-up. Although the quality of the intervention was rated positively, the results did not yield support for any differential effects of the intervention on drinking behavior or readiness to change at posttest and six-month follow-up. There were indications of changes in implicit and explicit alcohol-related cognitions between pretest and posttest. Our findings raise questions regarding the use of MI in this particular at-risk adolescent population and the mechanisms through which MI is effective.
doi:10.1037/a0013789
PMCID: PMC3140345  PMID: 19290699
implicit cognition; explicit cognition; adolescence; alcohol use; motivational interviewing
15.  Comparison of Indirect Assessments of Association as Predictors of Marijuana Use Among At-Risk Adolescents 
In this study, the authors compared indirect measures that attempt to quantify the level of marijuana associations among adolescents. They also evaluated whether these various methods overlap or tap different aspects of associative processes that may act in concert to influence marijuana use. Automatic drug-relevant associations were assessed in 121 at-risk youth in continuation high schools in California with the use of a word association index and computer-based, reaction time measures (i.e., Implicit Association Test [IAT] and Extrinsic Affective Simon Task [EAST]). Measures of working memory capacity, sensation seeking, and explicit cognitions also were included in analyses as potential confounders. The word association index and the marijuana IAT excited D measure were significant predictors of marijuana use. The word association index accounted for more variance in marijuana use than did the IAT or EAST measures. Further, confirmatory factor analytic models of the indirect measures of marijuana use revealed a significant moderate correlation between the EAST Excitement and Word Association factors but no significant correlations between the Word Association and IAT factors. These findings suggest that there is some convergence among the different indirect measures, but these assessments also appear to tap different aspects of associative processes. The types of indirect measures evaluated in this work provide information about spontaneous cognitions related to substance use, capturing influences on behavior that are not evaluated with traditional explicit assessments of behavior. Findings from this work add to a growing body of research that implicates the importance of implicit associative processes in risk and health behaviors.
doi:10.1037/1064-1297.15.2.218
PMCID: PMC3134415  PMID: 17469944
indirect assessment; implicit cognition; marijuana use; word association; IAT
16.  Working Memory Capacity Moderates the Predictive Effects of Drug-Related Associations on Substance Use 
Some theories suggest that spontaneously activated, drug-related associations in memory may have a “freer reign” in predicting drug use among individuals with lower working memory capacity. This study evaluated this hypothesis among 145 at-risk youth attending continuation high schools (CHS). This is the first study to evaluate this type of dual-process interaction in the prediction of drug use among a sample of at-risk adolescents. The CHS students completed assessments of drug-related memory associations, working memory capacity, and drug use. Control variables included age, gender, ethnicity, and acculturation. Robust multiple regression using least trimmed squares estimation indicated that there was a significant linear by linear interaction between working memory capacity as assessed with the self-ordered pointing task (SOPT) and drug-related associations (assessed with verb generation and cue-behavior association tasks) in the prediction of alcohol and cigarette use. Consistent with dual-process cognitive theories, drug-related associations in memory predicted drug use more strongly in students with lower levels of working memory capacity. These findings add to the literature implicating the influence of dual cognitive processes in adolescent risk behaviors.
doi:10.1037/0893-164X.22.3.426
PMCID: PMC3119708  PMID: 18778136
Substance use; adolescents; working memory; and implicit cognition

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