Less than meets the eye: Reappraising the clinical relevance of attentional bias in addiction

• Attentional bias is hypothesised to have clinical relevance in substance abusers.
• The association between attentional bias and relapse is inconsistent across studies.
• The effect of attentional bias modification on substance use is also inconsistent.
• Attentional bias is as a marker of the underlying motivational state.

Recent years have seen an explosion of interest in attentional bias in addiction, particularly its clinical relevance. Specifically, numerous articles claimed to demonstrate either that (1) attentional bias measured in treatment settings could predict subsequent relapse to substance use, or (2) direct modification of attentional bias reduced substance use and improved treatment outcomes. In this paper, we critically evaluate empirical studies that investigated these issues. We show that the evidence regarding both of these claims is decidedly mixed, and that many of the studies that appear to yield positive findings have serious methodological and statistical limitations. We contend that the available literature suggests that attentional bias for drug cues fluctuates within individuals because it is an output of the underlying motivational state at that moment in time, but there is no convincing evidence that it exerts a causal influence on substance use. Future research should make use of experience sampling methodology to characterise the clinical significance of fluctuations in attentional bias over time.