Episodic Future Thinking as an Intervention for Alcohol Use Disorder: Effects on Delay Discounting and Real-World Alcohol Consumption

Episodic Future Thinking as an Intervention for Alcohol Use Disorder: Effects on Delay Discounting and Real-World Alcohol Consumption | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Episodic Future Thinking as an Intervention for Alcohol Use Disorder: Effects on Delay Discounting and Real-World Alcohol Consumption Rafaela M. Fontes, Devin Tomlinson, Allison Tegge, Mikhail Koffarnus, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9182511/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Episodic future thinking (EFT) is a promising intervention for alcohol use disorder (AUD) as it has been shown to decrease delay discounting (DD) and alcohol valuation. In the current randomized controlled trial, we evaluated the effects of EFT on DD, behavioral economic demand, and daily measures of real-world alcohol consumption among individuals with AUD. Sixty-four non-treatment-seeking adults with AUD who wished to reduce or quit drinking but had no immediate treatment plans were randomized to EFT (n = 34) or control episodic thinking (CET; n = 30). Participants completed four in-laboratory sessions over the course of five weeks, and a follow-up in-laboratory session one month after the completion of the intervention. Additionally, alcohol consumption was monitored remotely for five weeks via a digital app. EFT exposure acutely decreased DD relative to baseline and CET. Additionally, daily exposure to the EFT, but not to CET, decreased the number of drinks/day and the number of drinks/drinking day. Significant changes in behavioral economic demand were not observed. Overall, the present findings suggest that EFT is a promising intervention to decrease alcohol use with effects on real-world alcohol consumption among individuals with alcohol use disorder, but alcohol demand is not a mechanism of this effect. Health sciences/Diseases/Psychiatric disorders/Addiction Biological sciences/Psychology/Human behaviour Biological sciences/Neuroscience/Learning and memory Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Alcohol use is a significant public health problem and contributes to more than 178,000 deaths annually in the US 1 . Nearly half of individuals aged 12 and older report past-month drinking, and 10% meet criteria for alcohol use disorder (AUD) 2 . Despite treatment availability, only 1 in 9 individuals with AUD benefit from medication 3 , 4 , and brief psychotherapeutic interventions yield only modest reductions in drinking 5 , 6 . Moreover, fewer than 8% of individuals with AUD receive any treatment 7 , highlighting the need for low-burden, scalable interventions that support behavior change and decrease daily alcohol consumption. One promising approach is episodic future thinking (EFT), an intervention grounded in the science of prospection that prompts participants to think about positive future events that are likely to happen 8 , 9 . The application of EFT as an intervention for alcohol use is informed by the reinforcer pathology theory 10 , 11 , which posits that substance use is maintained by a combination of a preference for immediate over delayed outcomes and high substance valuation. According to reinforcer pathology, reinforcer value is determined by integrating expected benefits and harms over a temporal window. The temporal window can be quantified with delay discounting (DD), which refers to the relative preference for smaller sooner over larger later rewards 12 . Higher DD rates indicate shorter temporal windows and, thus, greater valuation of intense, reliable, and immediate reinforcers, such as alcohol, relative to reinforcers that accrue value over time, such as long-term health. EFT has been shown to lengthen the temporal window (i.e., decrease DD) and thus reduce the relative value of immediate reinforcers in favor of delayed 8 . Notably, reinforcing value can be measured through hypothetical behavioral economic demand tasks 13 – 15 and real-world consumption 16 . EFT has been shown to decrease both DD and valuation in alcohol 17 , 18 , cocaine 19 , and cigarette use 20 – 22 . However, examination of EFT effects on real-world alcohol consumption is limited. For example, Athamneh et al. 16 showed decreases in DD and daily drinking following EFT in a sample of individuals with AUD, but alcohol consumption was monitored only for two weeks. To advance toward real-world implementation, more research is needed to evaluate the effects of EFT on alcohol use under naturalistic conditions. Therefore, the goal of the current randomized controlled trial was to expand on the previous findings and evaluate the effects of EFT on DD, behavioral economic demand, and real-world alcohol consumption over a longer time frame than has been done previously. We hypothesized that EFT would decrease these measures among non-treatment-seeking individuals with AUD. Materials and Methods This was a parallel trial that examined active (EFT) versus control conditions. Participation in the study lasted about nine weeks. Participants completed four in-laboratory sessions (S1-S4) and daily remote drinking monitoring over the course of five weeks, and a follow-up in-laboratory session (S5) one month after the completion of the intervention. All study sessions (S1-S5) were conducted in the laboratory and included a battery of behavioral assessments. During S2 and S3, participants also completed a resting-state MRI, and the neuroimaging results will be reported in a separate manuscript. Drinking monitoring was conducted remotely through a phone app. Figure 1 shows the study timeline. Total compensation was approximately $ 700 for completion of all sessions and remote submissions. Detailed compensation structure can be found in the Supplemental Materials. All procedures were registered at ClinicalTrials.gov (NCT04125238) and received ethical approval from the institutional review board at Virginia Polytechnic and State University (Protocol No. 22–358). Participants Participants were recruited from the Roanoke, VA community via flyers posted in the community (e.g., bars, restaurants, grocery stores), word-of-mouth, electronic (e.g., Craigslist, Facebook, BuildClinical), and bus advertisements. All advertisement materials noted that this was not a treatment study, and participants were not informed about the aims of the study or the goal of the intervention. Eligibility was assessed with an online pre-screening questionnaire, including the Alcohol Use Disorder Identification Test (AUDIT), and DSM-5 questions about past 12-month substance use. Eligibility criteria to sign consent required participants to 1) be between 21–65 years old, 2) demonstrate high-risk or harmful drinking, defined as an AUDIT score ≥ 16, and 3) have a desire to quit or cut down their drinking, but no proximate plans to enroll in treatment. The goal of including individuals interested in reducing or stopping alcohol use was to focus on the relevant population for future studies. Participants were ineligible if they 1) met moderate to severe DSM-5 criteria for substance-use disorders other than alcohol, nicotine, or cannabis, 2) had a current diagnosis of a psychotic disorder, 3) had a history of seizure disorder or traumatic brain injury, 4) had contraindications for fMRI participation, or 5) reported current pregnancy or lactation. Eligibility to continue in the study was assessed again after a seven-day baseline remote drinking monitoring phase (Baseline Monitoring), which occurred between S1 and S2 (Week 1). Only participants who reported their consumed number of daily drinks on at least five of the seven days and met criteria for harmful drinking were invited to continue in the study. Harmful drinking was defined as consuming alcohol on at least four of the seven days, with either 1) at least four days of consuming four or more drinks, and/or 2) an average of more than four drinks/drinking day. The purpose of the Baseline Monitoring phase was to quantify baseline drinking patterns and ensure that participants reliably responded to and conveyed study information remotely. Notably, there was only one exclusion exclusively due to a low number of submissions during baseline. A power analysis assuming a conservative medium effect size (f = 0.25 based on previous studies 16 , 17 ), a repeated measure correlation of 0.5, a Type I error rate of 0.01, and 80% statistical power indicated that 52 participants were needed to complete this study (n = 26 per group). G*Power was used to estimate sample size 23 . Because the longitudinal nature of the study and the baseline drinking requirements could contribute to high drop-out rates, we continued to enroll participants until 52 participants completed the one-month follow-up session (S5). Interventions Participants who met the baseline drinking criteria were invited to continue in the study and randomized to EFT or control episodic thinking (CET). Participants were randomly assigned to EFT (n = 34) or CET (n = 30) with an even allocation ratio. As done previously 24 – 26 , the randomization procedure used a computerized algorithm that adjusted the probability of group assignment and biased the allocation to balance the groups on number of drinks/day (square-root transformed to reduce bias from a skewed distribution) and baseline DD rates. Participants in both groups underwent two interview-guided EFT/CET cue generation sessions at S2 and S3, and were exposed to their EFT/CET cues daily for four weeks (Weeks 2–5 between S2 and S4). Cue Generation During the interview-guided EFT/CET cue generation sessions, participants in both groups were prompted to think vividly and describe in detail positive events for different time points. The only difference between the groups was the time orientation for the events. Those in the EFT group were prompted to think about events that would happen in the future (i.e., 1 day, 2 weeks, 1 month, 3 months, 1 year, 5 years, and 25 years in the future). Those in the CET group were prompted to think about events that occurred in the recent past (i.e., last night from 7 pm − 10 pm, yesterday between 4 pm − 7 pm, yesterday between 1 pm − 4 pm, yesterday from 10 am − 12 pm, yesterday between 7 am − 10 am, the night before last between 7 pm − 10 pm, and evening before last between 4 pm − 7 pm). Participants were prompted to think about one event per time point and asked a series of standard questions to help them think about the details of the event (e.g., where they are/were, who they are/were with, how they are/were feeling, etc.). Participants then provided a description of the event (long cue) and a short phrase to function as a reminder (short cue; see Supplemental Materials for examples of long and short cues). Cue exposure Participants received reminders 16 , 27 about their EFT/CET events (i.e., short cues) through SMS text twice daily (at 10am and 4pm). The short cues were texted in a random order (except for the 1-day EFT cue, which was not texted to the participants). The texts also included a randomly selected question designed to increase engagement with the cue (see Supplemental Materials for the complete list of questions), and participants received $ 1 for responding to it. Measurements Delay Discounting. During each in-laboratory session (S1-S5), participants completed an adjusting-amount DD task, where they were presented with choices between smaller-sooner and larger-later amounts of money. The task included seven delays between 1 day and 25 years in the future, and six trials for each delay. The larger-later amount remained constant at $ 1000 across trials, and the smaller-sooner amount was titrated according to the participant’s previous choice, as described in Du et al. 28 . During S2 and S3, participants’ long cues were displayed above each choice (see Supplemental Materials for example). In the EFT group, cues were matched to their corresponding delay (i.e., 1-day cue shown during 1-day delay choices). In the CET group, the cues corresponded to their proximity to the present (e.g., last night from 7pm-10pm cue shown during 1-day delay choices). Cues were not shown during S1, S4, and S5. Alcohol purchase task (APT). During each in-laboratory session (S1-S5), participants completed the APT where they were presented with a list of 13 prices in ascending order 29 and instructed to indicate how many standard drinks (i.e., 12 oz beer, 5 oz glass of wine, 1.5 oz hard liquor) they would buy at each price. Prices ranged from $ 0.00 to $ 80/drink. Because APT does not include a temporal component, participants in both groups saw a list of their long cues on top of the price list in S2 and S3 (see Supplemental Materials for example). Cues were not shown during S1, S4, and S5. Alcohol Consumption. During the first five weeks of the study (Weeks 1–5, between S1-S4), participants were required to report the number of drinks consumed per day and provide three breath samples/day. All participants were provided a BACtrack Mobile breathalyzer, an FDA-approved personal breathalyzer. Daily number of drinks and breath samples were measured using the Healthier Futures app developed for other ongoing research (R01AA026605) that connects to the BACTrack Mobile breathalyzer via Bluetooth. The app also collected an image of the participant’s face during breath submission for identity verification. The app was only available for Android, and participants who did not have an Android smartphone were provided with one (n = 39). Every morning, participants were asked to report the number of alcoholic drinks they consumed the previous day via the app. Previous-day consumption, instead of same-day consumption, was preferred to best capture all drinks consumed each day without inconsistent response times compromising the accuracy of the measure. Participants received $ 1 for reporting their number of drinks, regardless of the results. Breathalyzer screens were spaced at random times throughout the day, spanning the participant’s waking hours. Participants had 90 minutes to complete each breath sample submission and received $ 1 per sample submitted within the time window, regardless of the result. To encourage participants to provide all daily submissions, participants received a bonus for each day in which all submissions were completed (see Supplemental Materials for payment structure for the remote monitoring). The remote monitoring lasted approximately 35 days (see Fig. 1 ). Because the length of the monitoring phases was contingent on session completion (i.e., baseline monitoring ended at S2, monitoring phase 1 ended at S3, and monitoring phase 2 ended at S4), the duration of the phases varied across participants (e.g., due to the participant or staff availability for the sessions). Tables S1 and S2 show mean and median length of each monitoring phase per group. Data Analysis The Statistical Analysis Plan was pre-registered on the Open Science Framework (OSF) and can be found at https://osf.io/7vd6x/?view_only=5d2b2b498de9407fa1ed32251fbb1aa1 . Any deviations from the SAP are noted in this section. All analyses were conducted using R software (version 4.2.2). Complete case and intention-to-treat analyses were performed for all outcomes. For the complete case analyses, only participants who completed all sessions, including the one-month follow-up (i.e., S5; EFT = 28, CET = 24) were included. For the intention-to-treat analyses, all participants who initiated the intervention (i.e., S2; EFT = 33, CET = 28) were included, and all sessions following discontinuation were treated as missing data. Additionally, for participants who did not complete the intervention, all daily submission data up to their last submission of drink count or breath sample were included in the intention-to-treat analyses. All intention-to-treat analyses are included in the Supplemental Materials. For all statistical analyses, significance was set at p<.05. Follow-up pairwise comparisons for any significant main effects or interactions were conducted on estimated marginal means, and significance was based on Kenward-Rodger degrees of freedom 30 . All follow-up pairwise comparisons were corrected using the Tukey method. Discounting data were screened for systematicity using the Johnson and Bickel criteria 31 ; however, all data were analyzed, regardless of systematicity violations ( Tables S3-S4 show proportion of nonsystematic data). DD rates were calculated using Eq. 1 32 , where V represents the indifference point between the smaller-sooner and larger-later rewards, A represents the amount of the larger-later, k is the discounting rate, and D represents the delay. DD rates ( k ) were natural-logarithmic transformed (ln( k )) to fulfill the normality assumption. A linear mixed-effects model including fixed effects of group (EFT/CET), session (S1-S5), and group and session interaction, and a random intercept of participants were conducted using ln( k ) as outcome. The model was adjusted for age, sex, education, income, and AUDIT score. $$\:V=\frac{a}{1+kD}$$ 1 Responses to the APT were screened for overconsumption, defined as purchases of more than 50 drinks/price for self-consumption over 24-hours. Thus, consumption during the purchase task was capped at 50 drinks at any given price, such that any number of drinks greater than 50 was transformed to 50 (n = 11 observations). Data from the purchase task were used to estimate intensity (i.e., consumption at price $ 0), alpha (i.e., elasticity of demand), O max (i.e., maximum expenditure), and P max (i.e., price at which O max occurs) using the beezdemand package 33 . Alpha was estimated based on fits of Eq. 2 34 to the data, where Q is the consumption at price C , Q 0 estimates consumption at price $ 0, α is the elasticity of demand, and k is the span of the function. $$\:Q=\:{Q}_{0}*{10}^{k({e}^{-a{Q}_{0}C}-1)}$$ 2 Separate generalized linear mixed-effects models including fixed effects of group (EFT/CET), session (S1-S5), and group and session interaction, and a random intercept of participants were conducted using each demand parameter (intensity, alpha, O max , and P max ) as outcomes. Poisson distribution was used for the model on intensity. Alpha was natural-logarithmically transformed to fulfill the normality assumption. For the alpha analysis, data for which the equation did not converge were excluded (n = 2 in S1; n = 1 in S2; n = 2 in S3; n = 2 in S4; n = 2 in S5). All models were adjusted for age, sex, education, income, and AUDIT score. Changes in alcohol consumption were analyzed using drinks/day and drinks/drinking day as outcomes. Separate generalized linear mixed-effects models including fixed effects of group (EFT/CET), phase (Baseline Monitoring, Monitoring Phase 1, and Monitoring Phase 2), and group and phase interaction, and a random intercept of participants were conducted for each outcome. Poisson distribution was used for both models. All models were adjusted for age, sex, education, income, and AUDIT score. For both the complete case and the intention-to-treat analyses, all missing drink counts were treated as missing. Due to the high rate of missing breath sample data, the analysis on dichotomous breathalyzer results (positive or negative) described in the SAP was not performed. Instead, we performed a Fisher’s exact test to explore the association between the reported drinking days and the biochemically validated breath data. Additionally, we explored the area under the receiver operating characteristics (ROC) curve to determine the utility of peak breath sample (i.e., highest breath sample per day) to predict days in which a participant consumed at least one drink. For both the Fisher’s exact test and the ROC analysis, breath sample readings ≥ .02% of breath alcohol concentration were considered positive 25 . Lastly, we also explored the variables that impacted adherence to remote reporting (i.e., predicted missing daily samples) by performing an exhaustive search of the model space 35 . Separate model selections were performed using drink counts and breath samples submission statuses (i.e., submitted or missing) as outcomes. The predictors included in the model selection for each outcome were group, phase, group and phase interaction, and demographics of age, sex, ethnicity, race, education, and income. Additionally, the model selection for missing breath samples also included time of submission (i.e., first, second, or third submission of the day), and interactions between time of submission and phase, and time of submission and group as predictors. The optimal model was the one with the lowest Bayesian Information Criteria (BIC). Results A total of 114 provided informed consent, 103 started the baseline monitoring phase, and 64 made it to the randomization phase and were randomized to EFT (n = 34) or CET (n = 30). Of those, 61 started the intervention (i.e., underwent the first cue generation; EFT = 33, CET = 28), and 52 completed the entire study, including the one-month follow-up (S6; EFT = 28, CET = 24). Reasons for discontinuation during intervention included voluntary withdrawal and loss to follow-up (i.e., participant stopped communication with the study team). Recruitment and data collection occurred between June 2022 and September 2024. Table 1 summarizes baseline characteristics for EFT (n = 28) and CET (n = 24) participants who completed the entire study ( Table S5 includes baseline characteristics for all participants who started the intervention, n = 61). All participants met DSM-5 criteria for AUD. Groups were well balanced across demographic measures and randomization variables (i.e., drinks/day and ln( k )). Table 1 Sample demographics n EFT CET 24 28 Age a 37.21 (12.59) 41.32 (13.39) Sex = Male b 16 (66.7) 17 (60.7) Ethnicity = NOT Hispanic or Latino b 23 (95.8) 26 (92.9) Race b Asian 1 (4.2) 0 (0.0) Black or African American 3 (12.5) 4 (14.3) More Than One Race 1 (4.2) 1 (3.6) Other 1 (4.2) 0 (0.0) White 18 (75.0) 23 (82.1) Education b High School (9 + years) 5 (20.8) 5 (17.9) College (13 + years) 15 (62.5) 17 (60.7) Graduate School (17 + years) 4 (16.7) 6 (21.4) Employment b Retired 3 (13.0) 1 (3.6) Unemployed 2 (8.7) 1 (3.6) Working full time 12 (52.2) 19 (67.9) Working part-time 6 (26.1) 7 (25.0) Income b Less than $ 5,000 2 (8.3) 4 (14.3) $ 5,000 through $ 24,999 4 (16.7) 5 (17.9) $ 25,000 through $ 49,999 8 (33.3) 7 (25.0) $ 50,000 through $ 74,999 3 (12.5) 4 (14.3) $ 75,000 through $ 99,999 2 (8.3) 4 (14.3) $ 100,000 and greater 4 (16.7) 4 (14.3) No response 1 (4.2) 0 (0.0) Baseline DD rate (ln(k)) a -5.09 (2.54) -4.83 (2.53) AUDIT a 21.92 (3.68) 24.68 (4.90) AUD score a 8.42 (2.02) 7.75 (2.55) Cannabis Use Disorder 1.08 (1.82) 0.93 (2.11) Tobacco Use Disorder 0.04 (0.20) 0.00 (0.00) Opioid Use Disorder (Mild) 0.04 (0.20) 0.00 (0.00) Stimulants Use Disorder (Mild) 0.96 (1.99) 1.28 (3.02) Cocaine Use Disorder (Mild) 0.00 (0.00) 0.11 (0.57) Baseline drinks/day a 5.63 (2.23) 5.30 (2.08) Note: aMean (SD); bCount (%) Delay Discounting Figure 2 shows ln(k) across sessions. The linear mixed-effects model for ln( k ) indicated a significant Session and Group interaction (p<.001). The main effects of Session ( p =.80) and Group ( p =.45) were not significant (see Table S6 for model estimates). Follow-up pairwise comparisons indicated that ln(k) was significantly lower in the EFT group during the cue generation sessions (S2 and S3) compared to both baseline (S1; p s<.001) and end-of-intervention (S4; p s.19). In contrast, ln(k) did not vary significantly across sessions in the CET group ( p s>.86). Between-group differences were significant at S2 and S3 ( p s.41). These findings demonstrate that exposure to EFT, but not to CET, acutely reduced DD rates. Similar results were observed in the intention-to-treat analyses (see Table S6 ). Behavioral Economic Demand The generalized mixed-effects models for intensity, alpha, O max , and P max revealed no significant main effects of Group, Session, or Group and Session interaction. Tables S7-S10 show the model estimates for each outcome. These results suggest that no reliable effects of EFT were observed on alcohol demand. Similar results were observed in the intention-to-treat analyses (see Tables S7-S10 ). Alcohol Consumption Figures 3 and 4 show average drinks/day and average drinks/drinking day, respectively. Average drinks/day was calculated per participant by dividing the total drinks per phase by the total days in that phase. The average drinks/drinking day was calculated per participant by dividing the total drinks per phase by the number of days with at least one drink reported in that phase. The generalized mixed-effects model for drinks/day indicated a significant main effect of Phase ( p >.01) and Phase and Group interaction ( p <.001). The main effect of Group was not significant ( p =.76; see Table S11 for model estimates). Follow-up pairwise comparisons across phases indicated that the EFT group had a significantly lower drinks/day during the monitoring phase 1 ( p <.01) and monitoring phase 2 ( p <.001) relative to baseline monitoring, and during the monitoring phase 2 relative to the monitoring phase 1 ( p <.001). For the CET group, drinks/day were significantly lower during the monitoring phase 1 relative to the baseline monitoring ( p =.02) and to the monitoring phase 2 ( p .12). The generalized mixed-effects model for drinks/drinking day indicated a significant Phase and Group interaction ( p <.01). The main effects of Phase ( p =.17) and Group ( p =.60) were not significant (see Table S12 for the model estimates). Follow-up pairwise comparisons across phases indicated that the EFT group had a significantly lower drinks/drinking day during the monitoring phase 1 ( p <.01) and monitoring phase 2 ( p <.01) relative to the baseline monitoring, but significant differences between the monitoring phases 1 and 2 were not observed ( p =.77). For the CET group, pairwise comparisons did not indicate significant differences in drinks/drinking day across phases ( p s>.14). Pairwise comparisons between groups showed no significant differences at any phase ( p s>.28). Overall, these results suggest that drinks/day and drinks/drinking day consistently decreased across phases for the EFT but not for the CET group. We observed a higher proportion of missing breath samples than missing drink counts throughout the study (see Table S13 for proportion of submitted drink counts and breath samples). Despite the high proportion of missing breath samples, the Fisher’s exact test showed a significant association (OR: 16.60; p <.001) between breath sample results (positive or negative sample) and drink counts (positive or negative drink count), where the odds of a positive breath sample was about 16 times higher when participants reported at least one drink compared to zero drinks. Additionally, the AUC for the ROC curve was 0.79, indicating moderate discrimination. Table 2 shows the matrix comparing breath sample and drink count results. Noteworthy, most inconsistent responses correspond to individuals who had negative breath samples but self-reported at least one drink. One possible reason for this inconsistency is that participants could have provided a negative breath sample before starting drinking and not provided the following samples for that day. Notably, all findings for the alcohol consumption were replicated in the intention-to-treat analyses (see Tables S11-S14 ). Table 2 Matrix of breath samples and self-reported drink counts. Results from the model selection indicated that phase was the best predictor for missing drink count and missing breath samples. For both outcomes (i.e., drink count and breath samples), the odds of missing a daily submission during the monitoring phase 2 were significantly higher than for the other two monitoring phases, but not different between baseline and monitoring phase 1 (see Tables S15-S16 for model estimates). Notably, group assignment was not a predictor of missing drink count and breath samples. These results suggest that compliance with the remote procedures decreased with time into the study, regardless of group assignment. These findings were replicated in the intention-to-treat analyses (see Tables S15-S16 ). Discussion The present study evaluated the effects of EFT on DD, behavioral economic demand, and real-world alcohol consumption in a non-treatment-seeking AUD sample. Aligned with our hypotheses, the results showed 1) decreases in DD rates in the presence of the EFT, but not CET, cues, and 2) decreases in drinks/day and drinks/drinking day with daily exposure to EFT, but not to CET. However, contrary to our hypothesis, EFT did not impact alcohol demand. First, the present results replicate previous findings showing that EFT decreases DD rates 8 , 36 . Notably, in the present study, EFT only decreased DD rates when the cues were presented during the task. Thus, although EFT increases preference for the delayed reinforcers, those effects might not generalize when the cues are not available. Studies exploring how to increase the generalizability and duration of EFT effects are warranted before we can fully understand EFT’s long-term effects on decision-making. Second, the present results replicate and extend previous findings 16 , 37 showing that EFT decreases real-world alcohol consumption (measured as either drinks/day or drinks/drinking day). Furthermore, we showed this reduction across a 4-week intervention following two cue generation sessions, an extension of the previous study that investigated changes in drinking during a 2-week intervention following one cue generation. Thus, the present results demonstrate that daily exposure to EFT can sustain reduced alcohol consumption for a longer period than previously demonstrated. However, significant differences between groups were not observed. The lack of significant group effects in daily drinking remains unclear. Notably, EFT decreased alcohol consumption in individuals with AUD who had a desire to quit but no immediate plans to enroll in treatment. Thus, EFT might be efficacious for non-treatment-seeking individuals. Lastly, we did not observe EFT effects on alcohol demand. The reason for the lack of effect is unclear, especially considering the observed changes in alcohol consumption. One possible explanation for this lack of effect could be an insensitivity of the task to capture changes in valuation. For example, although the instructions specified the standard sizes of different types of drinks (e.g., 12 oz beer, 5 oz glass of wine, 1.5 oz shot of hard liquor), we did not ask what type of alcoholic beverage participants were considering when making their choices during the task. EFT might have impacted the type of drink purchased, and in turn the unit price (e.g., price per ounce) the participant was working with across sessions. Thus, purchase patterns may have changed across sessions in ways that were not captured by number of drinks purchased. Additionally, during the task, participants were instructed to purchase for 24-hour consumption. Thus, participants could have responded in a way that was representative of their typical drinking pattern instead of the pattern they intended to follow moving forward. It is also important to note that EFT effects on demand parameters have not been consistently observed 38 and are mainly observed for intensity 22 , 39 . Thus, more studies investigating the optimal conditions under which EFT impacts demand parameters are needed. Nonetheless, significant decreases in daily alcohol consumption were observed, even in the absence of changes in demand. This finding may indicate that EFT was effective in decreasing alcohol valuation, without impacting demand or that our assessment of demand needs further refinement (including possibly real-world purchase behavior). Alternatively, this finding may suggest that, despite the theoretical prediction, extending the temporal window may reduce consumption independent of changing alcohol reinforcing value. In that case, EFT might affect decision-making pathways other than reinforcement value. For example, EFT may impact motivation to consume without necessarily decreasing the value associated with the reinforcer. Some limitations are worth noting. First, most of the sample was white, educated, and currently employed, which might limit the generalizability of the results. Second, we observed an increasing proportion of missing data for the daily reports with study progression, which might indicate that the remote monitoring was burdensome and led to decreased compliance with extended participation. This might have been especially true for participants who had to use a study phone, instead of their own phones, for their daily submissions. Additionally, the time windows for breath sample submissions were random and could happen at inconvenient times for the participants. Similarly, the daily cue reminders were sent at fixed times, which could not align with peak craving or drinking time. Thus, whether more robust effects could have been observed with more frequent reminders or self-selected time windows remains unclear. Third, the length of the monitoring phases was contingent on session completion; thus, participant and staff availability for the sessions impacted phase duration. This difference in phase length should not impact the conclusions about changes in consumption, given that consumption analyses accounted for the number of days in each phase. However, it is unclear whether the additional EFT exposure for those with longer phases could have a differential impact on the outcomes. Fourth, our measure of drinks/day was based on self-report. Although we showed a significant association between breath sample results and drink counts, providing biochemical verification of our self-reported data, we recognize that this association does not provide evidence of the accuracy of the number of drinks reported. Thus, direct measures of drinking behavior are recommended in future trials. Additionally, linking the cue exposure more directly to observed drinking behavior could produce more robust effects of EFT on drinking. Adherence to the intervention could be improved in future studies by using patient-centered approaches in study design, allowing participants to select most convenient/effective monitoring and cue reminder windows, or tailoring these windows based on drinking patterns or ecological momentary assessments of craving. The use of less burdensome biological verification of alcohol use, such as transdermal alcohol sensors, could also decrease barriers to compliance and improve adherence to the intervention. Furthermore, studies are still needed to identify the optimal conditions under which EFT produces generalizable and long-lasting effects. Studies including longer follow-up monitoring and drinking measures post-intervention are also needed to evaluate whether the decrease in drinking is sustained after discontinuation of the daily reminders. Future studies should also include a more diverse population, especially underserved populations that are more largely affected by AUD. This could be achieved, for example, by using targeted recruitment strategies and including individuals with lived experiences in the recruitment and study design team. Overall, the present findings provide evidence of EFT effectiveness in decreasing discounting and real-world daily drinking. Notably, daily exposure to EFT decreased alcohol consumption in individuals with AUD who had a desire to quit but no immediate plans to enroll in treatment. EFT may be a particularly relevant intervention given its easy implementation with remote delivery, allowing it to be used with hard-to-reach populations 24 and integrated with other therapeutic approaches to augment their effect 40 , 41 . For example, EFT may be useful as an adjunctive therapy to other digital approaches such as app-based contingency management or cognitive behavioral therapy. EFT may be especially complementary to contingency management approaches, as contingency management is sometimes associated with short-term effects, while the decrease in discounting associated with EFT may lead to longer-term effects. Furthermore, EFT might be more acceptable for non-treatment-seeking individuals, as it does not focus on alcohol specifically. Future studies can continue to inform how EFT can be best tailored to produce the most effective and robust results. Declarations Conflict of Interests Although the following activities/relationships do not create a conflict of interest pertaining to this manuscript, in the interest of full disclosure: Dr. Tegge works on a project supported by Indivior, Inc. Dr. Kablinger’s research funding within the last 2 years include: Gilead, Curemark, ALTO, Liva Nova, and BEAM Diagnostics. Dr. MacKillop is a principal and senior scientist in Beam Diagnostics, Inc. Acknowledgement This study was supported by the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health (grant number R01AA027381). James MacKillop is supported by the Peter Boris Chair in Addictions Research and a Canada Research Chair in Translational Addiction Research (CRC-2020-00170). References Alcohol-Related Emergencies and Deaths in the United States. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics-z/alcohol-facts-and-statistics/alcohol-related-emergencies-and-deaths-united-states#:~ :text=The%20Alcohol%2DRelated%20Disease%20Impact,States%2C%20behind%20tobacco%2C%20poor%20diet. 2023 NSDUH Detailed Tables. https://www.samhsa.gov/data/report/2023-nsduh-detailed-tables . Rösner, S. et al. Acamprosate for alcohol dependence. Cochrane Database Syst. Rev. 2011, CD004332 (2010). Srisurapanont, M. & Jarusuraisin, N. Opioid antagonists for alcohol dependence. Cochrane Database Syst. Rev. CD001867 (2005) doi: 10.1002/14651858.CD001867.pub2 . Foxcroft, D. R. et al. Motivational interviewing for the prevention of alcohol misuse in young adults. Cochrane Database Syst. Rev. 7, CD007025 (2016). Klimas, J. et al. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. Cochrane Database Syst. Rev. 11, CD009269 (2012). Alcohol Treatment in the United States. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics-z/alcohol-facts-and-statistics/alcohol-treatment-united-states#:~:text=According%20to%20the%202023%20 NSDUH%2C%202.2%20million%20adults%20ages%2018,treatment%20in%20the%20past%20year.&text=1%2C2-,This%20includes%3A,AUD%20in%20this%20age%20group. Bickel, W. K. et al. Episodic Future Thinking as a Promising Intervention for Substance Use Disorders: a Reinforcer Pathology Perspective. Current Addiction Reports 10, 494–507 (2023). Brown, J. M. & Stein, J. S. Putting prospection into practice: Methodological considerations in the use of episodic future thinking to reduce delay discounting and maladaptive health behaviors. Front Public Health 10, 1020171 (2022). Bickel, W. K., Tegge, A. N., Carr, K. A. & Epstein, L. H. Reinforcer pathology’s alternative reinforcer hypothesis: A preliminary examination. Health Psychol. 40, 881–886 (2021). Bickel, W. K., Witkiewitz, K., Athamneh, L. N. & Kuhlemeier, A. Recovery from alcohol use disorder: Reinforcer pathology theory, measurement, and methods. Alcohol Clin Exp Res (Hoboken) 48, 1626–1636 (2024). The Effect of Delay and of Intervening Events on Reinforcement Value. (Psychology Press, London, England, 2013). Murphy, J. G. & MacKillop, J. Relative reinforcing efficacy of alcohol among college student drinkers. Exp. Clin. Psychopharmacol. 14, 219–227 (2006). DeGrandpre, R. J., Bickel, W. K., Higgins, S. T. & Hughes, J. R. A behavioral economic analysis of concurrently available money and cigarettes. J. Exp. Anal. Behav. 61, 191–201 (1994). Jacobs, E. A. & Bickel, W. K. Modeling drug consumption in the clinic using simulation procedures: demand for heroin and cigarettes in opioid-dependent outpatients. Exp. Clin. Psychopharmacol. 7, 412–426 (1999). Athamneh, L. N. et al. Future thinking to decrease real-world drinking in alcohol use disorder: Repairing reinforcer pathology in a randomized proof-of-concept trial. Exp. Clin. Psychopharmacol. 30, 326–337 (2022). Snider, S. E., LaConte, S. M. & Bickel, W. K. Episodic Future Thinking: Expansion of the Temporal Window in Individuals with Alcohol Dependence. Alcohol. Clin. Exp. Res. 40, 1558–1566 (2016). Bulley, A. & Gullo, M. J. The influence of episodic foresight on delay discounting and demand for alcohol. Addict. Behav. 66, 1–6 (2017). Snider, S. E., Turner, J. K., McClure, S. M. & Bickel, W. K. Reinforcer pathology in cocaine use disorder: Temporal window determines cocaine valuation. Drug Alcohol Depend. 225, 108795 (2021). Stein, J. S. et al. Unstuck in time: episodic future thinking reduces delay discounting and cigarette smoking. Psychopharmacology (Berl.) 233, 3771–3778 (2016). Chiou, W.-B. & Wu, W.-H. Episodic Future Thinking Involving the Nonsmoking Self Can Induce Lower Discounting and Cigarette Consumption. J. Stud. Alcohol Drugs 78, 106–112 (2017). Stein, J. S., Tegge, A. N., Turner, J. K. & Bickel, W. K. Episodic future thinking reduces delay discounting and cigarette demand: an investigation of the good-subject effect. J. Behav. Med. 41, 269–276 (2018). Faul, F., Erdfelder, E., Lang, A.-G. & Buchner, A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav. Res. Methods 39, 175–191 (2007). Bayrakdarian, N. D. et al. Acceptability and feasibility of a mobile behavioral economic health intervention to reduce alcohol use in adults in rural areas. Drug Alcohol Depend. Rep. 11, 100225 (2024). Koffarnus, M. N., Bickel, W. K. & Kablinger, A. S. Remote alcohol monitoring to facilitate incentive-based treatment for alcohol use disorder: A randomized trial. Alcohol. Clin. Exp. Res. 42, 2423–2431 (2018). Koffarnus, M. N., Kablinger, A. S., Kaplan, B. A. & Crill, E. M. Remotely administered incentive-based treatment for alcohol use disorder with participant-funded incentives is effective but less accessible to low-income participants. Exp. Clin. Psychopharmacol. 29, 555–565 (2021). Patel, H. & Amlung, M. Acute and extended exposure to episodic future thinking in a treatment seeking addiction sample: A pilot study. J. Subst. Abuse Treat. 116, 108046 (2020). Du, W., Green, L. & Myerson, J. Cross-cultural comparisons of discounting delayed and probabilistic rewards. Psychol. Rec. 52, 479–492 (2002). Tomlinson, D. C. et al. Presentation matters: Effects of cigarette purchase task design on systematic data and purchasing behavior. Exp. Clin. Psychopharmacol. 31, 1017–1022 (2023). Estimated Marginal Means, aka Least-Squares Means [R package emmeans version 2.0.2]. Comprehensive R Archive Network (CRAN) https://cran.r-project.org/package=emmeans (2026). Johnson, M. W. & Bickel, W. K. An algorithm for identifying nonsystematic delay-discounting data. Exp. Clin. Psychopharmacol. 16, 264–274 (2008). Mazur, J. E. An adjusting procedure for studying delayed reinforcement. in Quantitative analysis of behavior (ed. M.L. Commons, J.E. Mazur, J.A. Nevin, & H. Rachlin) 55–73 (Psychology Press, New York, NY, 1987). Kaplan, B. A., Gilroy, S. P., Reed, D. D., Koffarnus, M. N. & Hursh, S. R. The R package beezdemand: Behavioral Economic Easy Demand. Perspect Behav Sci 42, 163–180 (2019). Koffarnus, M. N., Franck, C. T., Stein, J. S. & Bickel, W. K. A modified exponential behavioral economic demand model to better describe consumption data. Exp. Clin. Psychopharmacol. 23, 504–512 (2015). Xu, S., Ferreira, M. A. R. & Tegge, A. N. What is in the model? A Comparison of variable selection criteria and model search approaches. arXiv [stat.ME] (2025). Rösch, S. A., Stramaccia, D. F. & Benoit, R. G. Promoting farsighted decisions via episodic future thinking: A meta-analysis. J. Exp. Psychol. Gen. 151, 1606–1635 (2022). Voss, A. T., Jorgensen, M. K. & Murphy, J. G. Episodic future thinking as a brief alcohol intervention for heavy drinking college students: A pilot feasibility study. Exp. Clin. Psychopharmacol. 30, 313–325 (2022). Stein, J. S. et al. Bleak present, bright future: II. Combined effects of episodic future thinking and scarcity on delay discounting in adults at risk for type 2 diabetes. J. Behav. Med. 44, 222–230 (2021). Zvorsky, I. et al. Sensitivity of hypothetical purchase task indices when studying substance use: A systematic literature review. Prev. Med. 128, 105789 (2019). García-Pérez, Á., Aonso-Diego, G., Weidberg, S. & Secades-Villa, R. Effects of episodic future thinking on reinforcement pathology during smoking cessation treatment among individuals with substance use disorders. Psychopharmacology 239, 631–642 (2022). Aonso-Diego, G., González-Roz, A., Krotter, A., García-Pérez, A. & Secades-Villa, R. Contingency management for smoking cessation among individuals with substance use disorders: In-treatment and post-treatment effects. Addict. Behav. 119, 106920 (2021). Additional Declarations The authors have declared there is NO conflict of interest to disclose Supplementary Files RPFTSupplementalMaterialsnewsubmission.docx Supplemental File Cite Share Download PDF Status: Under Review Version 1 posted Review # 2 received at journal 30 Apr, 2026 Review # 3 received at journal 25 Apr, 2026 Reviewer # 3 agreed at journal 18 Apr, 2026 Review # 1 received at journal 16 Apr, 2026 Reviewer # 2 agreed at journal 13 Apr, 2026 Reviewer # 1 agreed at journal 10 Apr, 2026 Reviewers invited by journal 28 Mar, 2026 Editor assigned by journal 25 Mar, 2026 Submission checks completed at journal 25 Mar, 2026 First submitted to journal 23 Mar, 2026 Unknown event 23 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Fontes","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIie3RsWrDMBCA4RMCd3HQesLtO1zxEEpCnyVG0IztaGhIr0uyBLp6CH2MzDGCdPEDZEzIC7hbTEupndJOkfHYQf8mcd8hEIDP9y8TO4AHUD+H9O9athBJAASaT0MFYLOFuxMx60D6cyvKkm5RRS/5vnq1U8VhfwfpIGEHuSyM1BkZ1Esr497KIq7Da4Zi7CQI9+soJDmlrQkisbpDgiBhMbNuog7y45OesCYXVbX8JV8tBOvlQLYhAfR4WBOZs+A2cghuFvSGOjNxFG6GOrMyz0abcex+mJHbY/qICpP9+3GCSs2fuSwngysXOVPzI6Pu4z6fz+c70zf/ZE8ss6Ol/AAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-9736-2854","institution":"Fralin Biomedical Research Institute","correspondingAuthor":true,"prefix":"","firstName":"Rafaela","middleName":"M.","lastName":"Fontes","suffix":""},{"id":613812101,"identity":"712c5e79-6458-4c7f-8a5a-14cb38eebe02","order_by":1,"name":"Devin Tomlinson","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Devin","middleName":"","lastName":"Tomlinson","suffix":""},{"id":613812102,"identity":"3faec325-1cdb-470c-b52f-ac2933223419","order_by":2,"name":"Allison Tegge","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Allison","middleName":"","lastName":"Tegge","suffix":""},{"id":613812103,"identity":"fbb8701f-a81a-4272-a25f-9a7d06deabbf","order_by":3,"name":"Mikhail Koffarnus","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Mikhail","middleName":"","lastName":"Koffarnus","suffix":""},{"id":613812104,"identity":"d75a9716-bc33-4aea-8537-b473e3320c73","order_by":4,"name":"Jeffrey Stein","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Jeffrey","middleName":"","lastName":"Stein","suffix":""},{"id":613812105,"identity":"3b230508-19a8-4ec2-ae38-b2502db226fc","order_by":5,"name":"Samuel McClure","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"","lastName":"McClure","suffix":""},{"id":613812106,"identity":"32da2fda-f579-4534-b465-06c4f78505de","order_by":6,"name":"Jeremy Myslowski","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Jeremy","middleName":"","lastName":"Myslowski","suffix":""},{"id":613812107,"identity":"82fcda4a-876f-4329-9441-c007633f989d","order_by":7,"name":"Rebecca Faubion-Trejo","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Rebecca","middleName":"","lastName":"Faubion-Trejo","suffix":""},{"id":613812108,"identity":"9e9967f6-d5d2-44ee-adea-264c0ae5f3e0","order_by":8,"name":"James MacKillop","email":"","orcid":"https://orcid.org/0000-0003-4118-9500","institution":"McMaster University","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"","lastName":"MacKillop","suffix":""},{"id":613812109,"identity":"dc53d732-5907-444e-be27-e8f70e61ba4c","order_by":9,"name":"Anita Kablinger","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Anita","middleName":"","lastName":"Kablinger","suffix":""},{"id":613812110,"identity":"8cc35aee-6cc3-48fb-8c37-b9697ba75e72","order_by":10,"name":"Stephen LaConte","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Stephen","middleName":"","lastName":"LaConte","suffix":""},{"id":613812111,"identity":"315a611a-8598-429f-a237-bd17e44f46cc","order_by":11,"name":"Warren Bickel","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Warren","middleName":"","lastName":"Bickel","suffix":""}],"badges":[],"createdAt":"2026-03-21 01:35:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9182511/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9182511/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106092179,"identity":"87947dfa-6562-43c5-a6bf-defa80903f7f","added_by":"auto","created_at":"2026-04-03 11:18:20","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":351951,"visible":true,"origin":"","legend":"\u003cp\u003eStudy timeline.\u003c/p\u003e","description":"","filename":"fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9182511/v1/f46bdbb0a6dbcbe6638b0188.jpg"},{"id":106414512,"identity":"e722a21f-52f4-4c8a-888d-ab9d1de9aac6","added_by":"auto","created_at":"2026-04-08 10:09:06","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":394212,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA) \u003c/strong\u003eAverage discounting rates across sessions for EFT and CET. \u003cstrong\u003eB)\u003c/strong\u003e Discounting rates across sessions for EFT. Grey lines represent individual data, and solid circles represent the group average. \u003cstrong\u003eC)\u003c/strong\u003e Discounting rates across sessions for CET. Grey lines represent individual data, and open circles represent the group average. In all panels, error bars represent the standard error of the mean (SEM). Uncued DD indicates sessions where the DD task was completed in the absence of EFT/CET cues. Cued DD indicates sessions where the DD task was completed in the presence of EFT/CET cues.\u003c/p\u003e","description":"","filename":"fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9182511/v1/56366d2de4192c4edee7dd1f.jpg"},{"id":106092181,"identity":"25511189-661a-42b6-8efc-defec95c1be2","added_by":"auto","created_at":"2026-04-03 11:18:20","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":386091,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA) \u003c/strong\u003eAverage drinks/day across monitoring phases for EFT and CET. \u003cstrong\u003eB)\u003c/strong\u003e Drinks/day across monitoring phases for EFT. Grey lines represent individual data, and solid circles represent the group average. \u003cstrong\u003eC) \u003c/strong\u003eDrinks/day across monitoring phases for CET. Grey lines represent individual data, and open circles represent the group average. In all panels, error bars represent the standard error of the mean (SEM).\u003c/p\u003e","description":"","filename":"fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9182511/v1/cf6b5598e9d36628f931b136.jpg"},{"id":106092183,"identity":"f3c18bae-41ce-44ea-bd88-594b5f51f836","added_by":"auto","created_at":"2026-04-03 11:18:20","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":359537,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA) \u003c/strong\u003eAverage drinks/drinking day across monitoring phases for EFT and CET. \u003cstrong\u003eB)\u003c/strong\u003e Drinks/drinking day across monitoring phases for EFT. Grey lines represent individual data, and solid circles represent the group average. \u003cstrong\u003eC) \u003c/strong\u003eDrinks/drinking day across monitoring phases for CET. Grey lines represent individual data, and open circles represent the group average. In all panels, error bars represent the standard error of the mean (SEM).\u003c/p\u003e","description":"","filename":"fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9182511/v1/354881a211a574095cdad556.jpg"},{"id":107704662,"identity":"b14688b1-3e75-4186-8e81-04f0d8174613","added_by":"auto","created_at":"2026-04-24 08:53:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1881533,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9182511/v1/127dcc87-2a38-4da5-bf36-ebe7f1e8bf82.pdf"},{"id":106414606,"identity":"9cde6fd1-a982-49a0-8096-9016b0639e64","added_by":"auto","created_at":"2026-04-08 10:14:23","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":270114,"visible":true,"origin":"","legend":"Supplemental File","description":"","filename":"RPFTSupplementalMaterialsnewsubmission.docx","url":"https://assets-eu.researchsquare.com/files/rs-9182511/v1/7e635316193ee097c9162865.docx"}],"financialInterests":"The authors have declared there is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose","formattedTitle":"Episodic Future Thinking as an Intervention for Alcohol Use Disorder: \r\nEffects on Delay Discounting and Real-World Alcohol Consumption","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAlcohol use is a significant public health problem and contributes to more than 178,000 deaths annually in the US\u003csup\u003e1\u003c/sup\u003e. Nearly half of individuals aged 12 and older report past-month drinking, and 10% meet criteria for alcohol use disorder (AUD)\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Despite treatment availability, only 1 in 9 individuals with AUD benefit from medication\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, and brief psychotherapeutic interventions yield only modest reductions in drinking\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Moreover, fewer than 8% of individuals with AUD receive any treatment\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, highlighting the need for low-burden, scalable interventions that support behavior change and decrease daily alcohol consumption.\u003c/p\u003e \u003cp\u003eOne promising approach is episodic future thinking (EFT), an intervention grounded in the science of prospection that prompts participants to think about positive future events that are likely to happen\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. The application of EFT as an intervention for alcohol use is informed by the reinforcer pathology theory\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, which posits that substance use is maintained by a combination of a preference for immediate over delayed outcomes and high substance valuation. According to reinforcer pathology, reinforcer value is determined by integrating expected benefits and harms over a temporal window. The temporal window can be quantified with delay discounting (DD), which refers to the relative preference for smaller sooner over larger later rewards\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Higher DD rates indicate shorter temporal windows and, thus, greater valuation of intense, reliable, and immediate reinforcers, such as alcohol, relative to reinforcers that accrue value over time, such as long-term health.\u003c/p\u003e \u003cp\u003eEFT has been shown to lengthen the temporal window (i.e., decrease DD) and thus reduce the relative value of immediate reinforcers in favor of delayed\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Notably, reinforcing value can be measured through hypothetical behavioral economic demand tasks\u003csup\u003e\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e and real-world consumption\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. EFT has been shown to decrease both DD and valuation in alcohol\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, cocaine\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, and cigarette use\u003csup\u003e\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. However, examination of EFT effects on real-world alcohol consumption is limited. For example, Athamneh et al.\u003csup\u003e16\u003c/sup\u003e showed decreases in DD and daily drinking following EFT in a sample of individuals with AUD, but alcohol consumption was monitored only for two weeks. To advance toward real-world implementation, more research is needed to evaluate the effects of EFT on alcohol use under naturalistic conditions. Therefore, the goal of the current randomized controlled trial was to expand on the previous findings and evaluate the effects of EFT on DD, behavioral economic demand, and real-world alcohol consumption over a longer time frame than has been done previously. We hypothesized that EFT would decrease these measures among non-treatment-seeking individuals with AUD.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis was a parallel trial that examined active (EFT) versus control conditions. Participation in the study lasted about nine weeks. Participants completed four in-laboratory sessions (S1-S4) and daily remote drinking monitoring over the course of five weeks, and a follow-up in-laboratory session (S5) one month after the completion of the intervention. All study sessions (S1-S5) were conducted in the laboratory and included a battery of behavioral assessments. During S2 and S3, participants also completed a resting-state MRI, and the neuroimaging results will be reported in a separate manuscript. Drinking monitoring was conducted remotely through a phone app. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the study timeline. Total compensation was approximately \u003cspan\u003e$\u003c/span\u003e700 for completion of all sessions and remote submissions. Detailed compensation structure can be found in the Supplemental Materials. All procedures were registered at ClinicalTrials.gov (NCT04125238) and received ethical approval from the institutional review board at Virginia Polytechnic and State University (Protocol No. 22\u0026ndash;358).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eParticipants were recruited from the Roanoke, VA community via flyers posted in the community (e.g., bars, restaurants, grocery stores), word-of-mouth, electronic (e.g., Craigslist, Facebook, BuildClinical), and bus advertisements. All advertisement materials noted that this was not a treatment study, and participants were not informed about the aims of the study or the goal of the intervention. Eligibility was assessed with an online pre-screening questionnaire, including the Alcohol Use Disorder Identification Test (AUDIT), and DSM-5 questions about past 12-month substance use. Eligibility criteria to sign consent required participants to 1) be between 21\u0026ndash;65 years old, 2) demonstrate high-risk or harmful drinking, defined as an AUDIT score\u0026thinsp;\u0026ge;\u0026thinsp;16, and 3) have a desire to quit or cut down their drinking, but no proximate plans to enroll in treatment. The goal of including individuals interested in reducing or stopping alcohol use was to focus on the relevant population for future studies. Participants were ineligible if they 1) met moderate to severe DSM-5 criteria for substance-use disorders other than alcohol, nicotine, or cannabis, 2) had a current diagnosis of a psychotic disorder, 3) had a history of seizure disorder or traumatic brain injury, 4) had contraindications for fMRI participation, or 5) reported current pregnancy or lactation.\u003c/p\u003e \u003cp\u003eEligibility to continue in the study was assessed again after a seven-day baseline remote drinking monitoring phase (Baseline Monitoring), which occurred between S1 and S2 (Week 1). Only participants who reported their consumed number of daily drinks on at least five of the seven days and met criteria for harmful drinking were invited to continue in the study. Harmful drinking was defined as consuming alcohol on at least four of the seven days, with either 1) at least four days of consuming four or more drinks, and/or 2) an average of more than four drinks/drinking day. The purpose of the Baseline Monitoring phase was to quantify baseline drinking patterns and ensure that participants reliably responded to and conveyed study information remotely. Notably, there was only one exclusion exclusively due to a low number of submissions during baseline.\u003c/p\u003e \u003cp\u003eA power analysis assuming a conservative medium effect size (f\u0026thinsp;=\u0026thinsp;0.25 based on previous studies\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e), a repeated measure correlation of 0.5, a Type I error rate of 0.01, and 80% statistical power indicated that 52 participants were needed to complete this study (n\u0026thinsp;=\u0026thinsp;26 per group). G*Power was used to estimate sample size\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Because the longitudinal nature of the study and the baseline drinking requirements could contribute to high drop-out rates, we continued to enroll participants until 52 participants completed the one-month follow-up session (S5).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInterventions\u003c/h3\u003e\n\u003cp\u003eParticipants who met the baseline drinking criteria were invited to continue in the study and randomized to EFT or control episodic thinking (CET). Participants were randomly assigned to EFT (n\u0026thinsp;=\u0026thinsp;34) or CET (n\u0026thinsp;=\u0026thinsp;30) with an even allocation ratio. As done previously\u003csup\u003e\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e, the randomization procedure used a computerized algorithm that adjusted the probability of group assignment and biased the allocation to balance the groups on number of drinks/day (square-root transformed to reduce bias from a skewed distribution) and baseline DD rates. Participants in both groups underwent two interview-guided EFT/CET cue generation sessions at S2 and S3, and were exposed to their EFT/CET cues daily for four weeks (Weeks 2\u0026ndash;5 between S2 and S4).\u003c/p\u003e\n\u003ch3\u003eCue Generation\u003c/h3\u003e\n\u003cp\u003e During the interview-guided EFT/CET cue generation sessions, participants in both groups were prompted to think vividly and describe in detail positive events for different time points. The only difference between the groups was the time orientation for the events. Those in the EFT group were prompted to think about events that would happen in the future (i.e., 1 day, 2 weeks, 1 month, 3 months, 1 year, 5 years, and 25 years in the future). Those in the CET group were prompted to think about events that occurred in the recent past (i.e., last night from 7 pm\u0026thinsp;\u0026minus;\u0026thinsp;10 pm, yesterday between 4 pm\u0026thinsp;\u0026minus;\u0026thinsp;7 pm, yesterday between 1 pm\u0026thinsp;\u0026minus;\u0026thinsp;4 pm, yesterday from 10 am\u0026thinsp;\u0026minus;\u0026thinsp;12 pm, yesterday between 7 am\u0026thinsp;\u0026minus;\u0026thinsp;10 am, the night before last between 7 pm\u0026thinsp;\u0026minus;\u0026thinsp;10 pm, and evening before last between 4 pm\u0026thinsp;\u0026minus;\u0026thinsp;7 pm). Participants were prompted to think about one event per time point and asked a series of standard questions to help them think about the details of the event (e.g., where they are/were, who they are/were with, how they are/were feeling, etc.). Participants then provided a description of the event (long cue) and a short phrase to function as a reminder (short cue; see Supplemental Materials for examples of long and short cues).\u003c/p\u003e\n\u003ch3\u003eCue exposure\u003c/h3\u003e\n\u003cp\u003eParticipants received reminders\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e about their EFT/CET events (i.e., short cues) through SMS text twice daily (at 10am and 4pm). The short cues were texted in a random order (except for the 1-day EFT cue, which was not texted to the participants). The texts also included a randomly selected question designed to increase engagement with the cue (see Supplemental Materials for the complete list of questions), and participants received \u003cspan\u003e$\u003c/span\u003e1 for responding to it.\u003c/p\u003e\n\u003ch3\u003eMeasurements\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003eDelay Discounting.\u003c/em\u003e During each in-laboratory session (S1-S5), participants completed an adjusting-amount DD task, where they were presented with choices between smaller-sooner and larger-later amounts of money. The task included seven delays between 1 day and 25 years in the future, and six trials for each delay. The larger-later amount remained constant at \u003cspan\u003e$\u003c/span\u003e1000 across trials, and the smaller-sooner amount was titrated according to the participant\u0026rsquo;s previous choice, as described in Du et al.\u003csup\u003e28\u003c/sup\u003e. During S2 and S3, participants\u0026rsquo; long cues were displayed above each choice (see Supplemental Materials for example). In the EFT group, cues were matched to their corresponding delay (i.e., 1-day cue shown during 1-day delay choices). In the CET group, the cues corresponded to their proximity to the present (e.g., last night from 7pm-10pm cue shown during 1-day delay choices). Cues were not shown during S1, S4, and S5.\u003c/p\u003e \u003cp\u003e \u003cem\u003eAlcohol purchase task (APT).\u003c/em\u003e During each in-laboratory session (S1-S5), participants completed the APT where they were presented with a list of 13 prices in ascending order\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e and instructed to indicate how many standard drinks (i.e., 12 oz beer, 5 oz glass of wine, 1.5 oz hard liquor) they would buy at each price. Prices ranged from \u003cspan\u003e$\u003c/span\u003e0.00 to \u003cspan\u003e$\u003c/span\u003e80/drink. Because APT does not include a temporal component, participants in both groups saw a list of their long cues on top of the price list in S2 and S3 (see Supplemental Materials for example). Cues were not shown during S1, S4, and S5.\u003c/p\u003e \u003cp\u003e\u003cem\u003eAlcohol Consumption.\u003c/em\u003e During the first five weeks of the study (Weeks 1\u0026ndash;5, between S1-S4), participants were required to report the number of drinks consumed per day and provide three breath samples/day. All participants were provided a BACtrack Mobile breathalyzer, an FDA-approved personal breathalyzer. Daily number of drinks and breath samples were measured using the Healthier Futures app developed for other ongoing research (R01AA026605) that connects to the BACTrack Mobile breathalyzer via Bluetooth. The app also collected an image of the participant\u0026rsquo;s face during breath submission for identity verification. The app was only available for Android, and participants who did not have an Android smartphone were provided with one (n\u0026thinsp;=\u0026thinsp;39).\u003c/p\u003e \u003cp\u003eEvery morning, participants were asked to report the number of alcoholic drinks they consumed the previous day via the app. Previous-day consumption, instead of same-day consumption, was preferred to best capture all drinks consumed each day without inconsistent response times compromising the accuracy of the measure. Participants received \u003cspan\u003e$\u003c/span\u003e1 for reporting their number of drinks, regardless of the results. Breathalyzer screens were spaced at random times throughout the day, spanning the participant\u0026rsquo;s waking hours. Participants had 90 minutes to complete each breath sample submission and received \u003cspan\u003e$\u003c/span\u003e1 per sample submitted within the time window, regardless of the result. To encourage participants to provide all daily submissions, participants received a bonus for each day in which all submissions were completed (see Supplemental Materials for payment structure for the remote monitoring). The remote monitoring lasted approximately 35 days (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Because the length of the monitoring phases was contingent on session completion (i.e., baseline monitoring ended at S2, monitoring phase 1 ended at S3, and monitoring phase 2 ended at S4), the duration of the phases varied across participants (e.g., due to the participant or staff availability for the sessions). \u003cb\u003eTables S1\u003c/b\u003e and \u003cb\u003eS2\u003c/b\u003e show mean and median length of each monitoring phase per group.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe Statistical Analysis Plan was pre-registered on the Open Science Framework (OSF) and can be found at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/7vd6x/?view_only=5d2b2b498de9407fa1ed32251fbb1aa1\u003c/span\u003e\u003cspan address=\"https://osf.io/7vd6x/?view_only=5d2b2b498de9407fa1ed32251fbb1aa1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Any deviations from the SAP are noted in this section. All analyses were conducted using R software (version 4.2.2). Complete case and intention-to-treat analyses were performed for all outcomes. For the complete case analyses, only participants who completed all sessions, including the one-month follow-up (i.e., S5; EFT\u0026thinsp;=\u0026thinsp;28, CET\u0026thinsp;=\u0026thinsp;24) were included. For the intention-to-treat analyses, all participants who initiated the intervention (i.e., S2; EFT\u0026thinsp;=\u0026thinsp;33, CET\u0026thinsp;=\u0026thinsp;28) were included, and all sessions following discontinuation were treated as missing data. Additionally, for participants who did not complete the intervention, all daily submission data up to their last submission of drink count or breath sample were included in the intention-to-treat analyses. All intention-to-treat analyses are included in the Supplemental Materials. For all statistical analyses, significance was set at p\u0026lt;.05. Follow-up pairwise comparisons for any significant main effects or interactions were conducted on estimated marginal means, and significance was based on Kenward-Rodger degrees of freedom\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. All follow-up pairwise comparisons were corrected using the Tukey method.\u003c/p\u003e \u003cp\u003eDiscounting data were screened for systematicity using the Johnson and Bickel criteria\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e; however, all data were analyzed, regardless of systematicity violations (\u003cb\u003eTables S3-S4\u003c/b\u003e show proportion of nonsystematic data). DD rates were calculated using Eq.\u0026nbsp;1\u003csup\u003e32\u003c/sup\u003e, where V represents the indifference point between the smaller-sooner and larger-later rewards, A represents the amount of the larger-later, \u003cem\u003ek\u003c/em\u003e is the discounting rate, and D represents the delay. DD rates (\u003cem\u003ek\u003c/em\u003e) were natural-logarithmic transformed (ln(\u003cem\u003ek\u003c/em\u003e)) to fulfill the normality assumption. A linear mixed-effects model including fixed effects of group (EFT/CET), session (S1-S5), and group and session interaction, and a random intercept of participants were conducted using ln(\u003cem\u003ek\u003c/em\u003e) as outcome. The model was adjusted for age, sex, education, income, and AUDIT score.\u003cdiv id=\"Equ1\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equ1\" name=\"EquationSource\"\u003e\n$$\\:V=\\frac{a}{1+kD}$$\u003c/div\u003e\u003cdiv class=\"EquationNumber\"\u003e1\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eResponses to the APT were screened for overconsumption, defined as purchases of more than 50 drinks/price for self-consumption over 24-hours. Thus, consumption during the purchase task was capped at 50 drinks at any given price, such that any number of drinks greater than 50 was transformed to 50 (n\u0026thinsp;=\u0026thinsp;11 observations). Data from the purchase task were used to estimate intensity (i.e., consumption at price \u003cspan\u003e$\u003c/span\u003e0), alpha (i.e., elasticity of demand), O\u003csub\u003emax\u003c/sub\u003e (i.e., maximum expenditure), and P\u003csub\u003emax\u003c/sub\u003e (i.e., price at which O\u003csub\u003emax\u003c/sub\u003e occurs) using the \u003cem\u003ebeezdemand\u003c/em\u003e package\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Alpha was estimated based on fits of Eq.\u0026nbsp;2\u003csup\u003e34\u003c/sup\u003e to the data, where \u003cem\u003eQ\u003c/em\u003e is the consumption at price \u003cem\u003eC\u003c/em\u003e, \u003cem\u003eQ\u003c/em\u003e\u003csub\u003e\u003cem\u003e0\u003c/em\u003e\u003c/sub\u003e estimates consumption at price \u003cspan\u003e$\u003c/span\u003e0, \u003cem\u003eα\u003c/em\u003e is the elasticity of demand, and \u003cem\u003ek\u003c/em\u003e is the span of the function.\u003cdiv id=\"Equ2\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equ2\" name=\"EquationSource\"\u003e\n$$\\:Q=\\:{Q}_{0}*{10}^{k({e}^{-a{Q}_{0}C}-1)}$$\u003c/div\u003e\u003cdiv class=\"EquationNumber\"\u003e2\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSeparate generalized linear mixed-effects models including fixed effects of group (EFT/CET), session (S1-S5), and group and session interaction, and a random intercept of participants were conducted using each demand parameter (intensity, alpha, O\u003csub\u003emax\u003c/sub\u003e, and P\u003csub\u003emax\u003c/sub\u003e) as outcomes. Poisson distribution was used for the model on intensity. Alpha was natural-logarithmically transformed to fulfill the normality assumption. For the alpha analysis, data for which the equation did not converge were excluded (n\u0026thinsp;=\u0026thinsp;2 in S1; n\u0026thinsp;=\u0026thinsp;1 in S2; n\u0026thinsp;=\u0026thinsp;2 in S3; n\u0026thinsp;=\u0026thinsp;2 in S4; n\u0026thinsp;=\u0026thinsp;2 in S5). All models were adjusted for age, sex, education, income, and AUDIT score.\u003c/p\u003e \u003cp\u003eChanges in alcohol consumption were analyzed using drinks/day and drinks/drinking day as outcomes. Separate generalized linear mixed-effects models including fixed effects of group (EFT/CET), phase (Baseline Monitoring, Monitoring Phase 1, and Monitoring Phase 2), and group and phase interaction, and a random intercept of participants were conducted for each outcome. Poisson distribution was used for both models. All models were adjusted for age, sex, education, income, and AUDIT score. For both the complete case and the intention-to-treat analyses, all missing drink counts were treated as missing.\u003c/p\u003e \u003cp\u003eDue to the high rate of missing breath sample data, the analysis on dichotomous breathalyzer results (positive or negative) described in the SAP was not performed. Instead, we performed a Fisher\u0026rsquo;s exact test to explore the association between the reported drinking days and the biochemically validated breath data. Additionally, we explored the area under the receiver operating characteristics (ROC) curve to determine the utility of peak breath sample (i.e., highest breath sample per day) to predict days in which a participant consumed at least one drink. For both the Fisher\u0026rsquo;s exact test and the ROC analysis, breath sample readings \u0026ge;\u0026thinsp;.02% of breath alcohol concentration were considered positive\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Lastly, we also explored the variables that impacted adherence to remote reporting (i.e., predicted missing daily samples) by performing an exhaustive search of the model space\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Separate model selections were performed using drink counts and breath samples submission statuses (i.e., submitted or missing) as outcomes. The predictors included in the model selection for each outcome were group, phase, group and phase interaction, and demographics of age, sex, ethnicity, race, education, and income. Additionally, the model selection for missing breath samples also included time of submission (i.e., first, second, or third submission of the day), and interactions between time of submission and phase, and time of submission and group as predictors. The optimal model was the one with the lowest Bayesian Information Criteria (BIC).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 114 provided informed consent, 103 started the baseline monitoring phase, and 64 made it to the randomization phase and were randomized to EFT (n\u0026thinsp;=\u0026thinsp;34) or CET (n\u0026thinsp;=\u0026thinsp;30). Of those, 61 started the intervention (i.e., underwent the first cue generation; EFT\u0026thinsp;=\u0026thinsp;33, CET\u0026thinsp;=\u0026thinsp;28), and 52 completed the entire study, including the one-month follow-up (S6; EFT\u0026thinsp;=\u0026thinsp;28, CET\u0026thinsp;=\u0026thinsp;24). Reasons for discontinuation during intervention included voluntary withdrawal and loss to follow-up (i.e., participant stopped communication with the study team). Recruitment and data collection occurred between June 2022 and September 2024.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes baseline characteristics for EFT (n\u0026thinsp;=\u0026thinsp;28) and CET (n\u0026thinsp;=\u0026thinsp;24) participants who completed the entire study (\u003cb\u003eTable S5\u003c/b\u003e includes baseline characteristics for all participants who started the intervention, n\u0026thinsp;=\u0026thinsp;61). All participants met DSM-5 criteria for AUD. Groups were well balanced across demographic measures and randomization variables (i.e., drinks/day and ln(\u003cem\u003ek\u003c/em\u003e)).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSample demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEFT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCET\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37.21 (12.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.32 (13.39)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u0026thinsp;=\u0026thinsp;Male\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (60.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u0026thinsp;=\u0026thinsp;NOT Hispanic or Latino\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (95.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (92.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack or African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore Than One Race\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (82.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh School (9\u0026thinsp;+\u0026thinsp;years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (17.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege (13\u0026thinsp;+\u0026thinsp;years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (60.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduate School (17\u0026thinsp;+\u0026thinsp;years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (21.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking full time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (52.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (67.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking part-time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncome\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than \u003cspan\u003e$\u003c/span\u003e5,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e5,000 through \u003cspan\u003e$\u003c/span\u003e24,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (17.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e25,000 through \u003cspan\u003e$\u003c/span\u003e49,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e50,000 through \u003cspan\u003e$\u003c/span\u003e74,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e75,000 through \u003cspan\u003e$\u003c/span\u003e99,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e100,000 and greater\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline DD rate (ln(k))\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-5.09 (2.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-4.83 (2.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAUDIT\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.92 (3.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.68 (4.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAUD score\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.42 (2.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.75 (2.55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCannabis Use Disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.08 (1.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.93 (2.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTobacco Use Disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.04 (0.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.00 (0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpioid Use Disorder (Mild)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.04 (0.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.00 (0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStimulants Use Disorder (Mild)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.96 (1.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.28 (3.02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCocaine Use Disorder (Mild)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.00 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.11 (0.57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline drinks/day\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.63 (2.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.30 (2.08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003eNote: aMean (SD); bCount (%)\u003c/p\u003e\n\u003ch3\u003eDelay Discounting\u003c/h3\u003e\n\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows ln(k) across sessions. The linear mixed-effects model for ln(\u003cem\u003ek\u003c/em\u003e) indicated a significant Session and Group interaction (p\u0026lt;.001). The main effects of Session (\u003cem\u003ep\u003c/em\u003e=.80) and Group (\u003cem\u003ep\u003c/em\u003e=.45) were not significant (see \u003cb\u003eTable S6\u003c/b\u003e for model estimates). Follow-up pairwise comparisons indicated that ln(k) was significantly lower in the EFT group during the cue generation sessions (S2 and S3) compared to both baseline (S1; \u003cem\u003ep\u003c/em\u003es\u0026lt;.001) and end-of-intervention (S4; \u003cem\u003ep\u003c/em\u003es\u0026lt;.01). No significant differences were observed between S2 and S3 (\u003cem\u003ep\u003c/em\u003e=.99) or between S2/S3 and follow-up (S5; \u003cem\u003ep\u003c/em\u003es\u0026gt;.19). In contrast, ln(k) did not vary significantly across sessions in the CET group (\u003cem\u003ep\u003c/em\u003es\u0026gt;.86). Between-group differences were significant at S2 and S3 (\u003cem\u003ep\u003c/em\u003es\u0026lt;.02), but not at S1, S4, or S5 (\u003cem\u003ep\u003c/em\u003es\u0026gt;.41). These findings demonstrate that exposure to EFT, but not to CET, acutely reduced DD rates. Similar results were observed in the intention-to-treat analyses (see \u003cb\u003eTable S6\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBehavioral Economic Demand\u003c/h2\u003e \u003cp\u003eThe generalized mixed-effects models for intensity, alpha, O\u003csub\u003emax\u003c/sub\u003e, and P\u003csub\u003emax\u003c/sub\u003e revealed no significant main effects of Group, Session, or Group and Session interaction. \u003cb\u003eTables S7-S10\u003c/b\u003e show the model estimates for each outcome. These results suggest that no reliable effects of EFT were observed on alcohol demand. Similar results were observed in the intention-to-treat analyses (see \u003cb\u003eTables S7-S10\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAlcohol Consumption\u003c/h2\u003e \u003cp\u003eFigures \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e show average drinks/day and average drinks/drinking day, respectively. Average drinks/day was calculated per participant by dividing the total drinks per phase by the total days in that phase. The average drinks/drinking day was calculated per participant by dividing the total drinks per phase by the number of days with at least one drink reported in that phase. The generalized mixed-effects model for drinks/day indicated a significant main effect of Phase (\u003cem\u003ep\u003c/em\u003e\u0026gt;.01) and Phase and Group interaction (\u003cem\u003ep\u003c/em\u003e\u0026lt;.001). The main effect of Group was not significant (\u003cem\u003ep\u003c/em\u003e=.76; see \u003cb\u003eTable S11\u003c/b\u003e for model estimates). Follow-up pairwise comparisons across phases indicated that the EFT group had a significantly lower drinks/day during the monitoring phase 1 (\u003cem\u003ep\u003c/em\u003e\u0026lt;.01) and monitoring phase 2 (\u003cem\u003ep\u003c/em\u003e\u0026lt;.001) relative to baseline monitoring, and during the monitoring phase 2 relative to the monitoring phase 1 (\u003cem\u003ep\u003c/em\u003e\u0026lt;.001). For the CET group, drinks/day were significantly lower during the monitoring phase 1 relative to the baseline monitoring (\u003cem\u003ep\u003c/em\u003e=.02) and to the monitoring phase 2 (\u003cem\u003ep\u003c/em\u003e\u0026lt;.01) but not different between the monitoring phase 2 and baseline (\u003cem\u003ep\u003c/em\u003e=.92). Pairwise comparisons between groups showed no significant differences in any phase (\u003cem\u003eps\u003c/em\u003e\u0026gt;.12).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe generalized mixed-effects model for drinks/drinking day indicated a significant Phase and Group interaction (\u003cem\u003ep\u003c/em\u003e\u0026lt;.01). The main effects of Phase (\u003cem\u003ep\u003c/em\u003e=.17) and Group (\u003cem\u003ep\u003c/em\u003e=.60) were not significant (see \u003cb\u003eTable S12\u003c/b\u003e for the model estimates). Follow-up pairwise comparisons across phases indicated that the EFT group had a significantly lower drinks/drinking day during the monitoring phase 1 (\u003cem\u003ep\u003c/em\u003e\u0026lt;.01) and monitoring phase 2 (\u003cem\u003ep\u003c/em\u003e\u0026lt;.01) relative to the baseline monitoring, but significant differences between the monitoring phases 1 and 2 were not observed (\u003cem\u003ep\u003c/em\u003e=.77). For the CET group, pairwise comparisons did not indicate significant differences in drinks/drinking day across phases (\u003cem\u003ep\u003c/em\u003es\u0026gt;.14). Pairwise comparisons between groups showed no significant differences at any phase (\u003cem\u003ep\u003c/em\u003es\u0026gt;.28). Overall, these results suggest that drinks/day and drinks/drinking day consistently decreased across phases for the EFT but not for the CET group.\u003c/p\u003e \u003cp\u003eWe observed a higher proportion of missing breath samples than missing drink counts throughout the study (see \u003cb\u003eTable S13\u003c/b\u003e for proportion of submitted drink counts and breath samples). Despite the high proportion of missing breath samples, the Fisher\u0026rsquo;s exact test showed a significant association (OR: 16.60; \u003cem\u003ep\u003c/em\u003e\u0026lt;.001) between breath sample results (positive or negative sample) and drink counts (positive or negative drink count), where the odds of a positive breath sample was about 16 times higher when participants reported at least one drink compared to zero drinks. Additionally, the AUC for the ROC curve was 0.79, indicating moderate discrimination. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the matrix comparing breath sample and drink count results. Noteworthy, most inconsistent responses correspond to individuals who had negative breath samples but self-reported at least one drink. One possible reason for this inconsistency is that participants could have provided a negative breath sample before starting drinking and not provided the following samples for that day. Notably, all findings for the alcohol consumption were replicated in the intention-to-treat analyses (see \u003cb\u003eTables S11-S14\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMatrix of breath samples and self-reported drink counts.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd\u003e\u003cp\u003e\u003cimg 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\" style=\"width: 428px; height: 220.028px;\" width=\"428\" height=\"220.028\"\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResults from the model selection indicated that phase was the best predictor for missing drink count and missing breath samples. For both outcomes (i.e., drink count and breath samples), the odds of missing a daily submission during the monitoring phase 2 were significantly higher than for the other two monitoring phases, but not different between baseline and monitoring phase 1 (see \u003cb\u003eTables S15-S16\u003c/b\u003e for model estimates). Notably, group assignment was not a predictor of missing drink count and breath samples. These results suggest that compliance with the remote procedures decreased with time into the study, regardless of group assignment. These findings were replicated in the intention-to-treat analyses (see \u003cb\u003eTables S15-S16\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study evaluated the effects of EFT on DD, behavioral economic demand, and real-world alcohol consumption in a non-treatment-seeking AUD sample. Aligned with our hypotheses, the results showed 1) decreases in DD rates in the presence of the EFT, but not CET, cues, and 2) decreases in drinks/day and drinks/drinking day with daily exposure to EFT, but not to CET. However, contrary to our hypothesis, EFT did not impact alcohol demand.\u003c/p\u003e \u003cp\u003eFirst, the present results replicate previous findings showing that EFT decreases DD rates\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. Notably, in the present study, EFT only decreased DD rates when the cues were presented during the task. Thus, although EFT increases preference for the delayed reinforcers, those effects might not generalize when the cues are not available. Studies exploring how to increase the generalizability and duration of EFT effects are warranted before we can fully understand EFT\u0026rsquo;s long-term effects on decision-making.\u003c/p\u003e \u003cp\u003eSecond, the present results replicate and extend previous findings\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e showing that EFT decreases real-world alcohol consumption (measured as either drinks/day or drinks/drinking day). Furthermore, we showed this reduction across a 4-week intervention following two cue generation sessions, an extension of the previous study that investigated changes in drinking during a 2-week intervention following one cue generation. Thus, the present results demonstrate that daily exposure to EFT can sustain reduced alcohol consumption for a longer period than previously demonstrated. However, significant differences between groups were not observed. The lack of significant group effects in daily drinking remains unclear. Notably, EFT decreased alcohol consumption in individuals with AUD who had a desire to quit but no immediate plans to enroll in treatment. Thus, EFT might be efficacious for non-treatment-seeking individuals.\u003c/p\u003e \u003cp\u003eLastly, we did not observe EFT effects on alcohol demand. The reason for the lack of effect is unclear, especially considering the observed changes in alcohol consumption. One possible explanation for this lack of effect could be an insensitivity of the task to capture changes in valuation. For example, although the instructions specified the standard sizes of different types of drinks (e.g., 12 oz beer, 5 oz glass of wine, 1.5 oz shot of hard liquor), we did not ask what type of alcoholic beverage participants were considering when making their choices during the task. EFT might have impacted the type of drink purchased, and in turn the unit price (e.g., price per ounce) the participant was working with across sessions. Thus, purchase patterns may have changed across sessions in ways that were not captured by number of drinks purchased. Additionally, during the task, participants were instructed to purchase for 24-hour consumption. Thus, participants could have responded in a way that was representative of their typical drinking pattern instead of the pattern they intended to follow moving forward. It is also important to note that EFT effects on demand parameters have not been consistently observed\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e and are mainly observed for intensity\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. Thus, more studies investigating the optimal conditions under which EFT impacts demand parameters are needed.\u003c/p\u003e \u003cp\u003eNonetheless, significant decreases in daily alcohol consumption were observed, even in the absence of changes in demand. This finding may indicate that EFT was effective in decreasing alcohol valuation, without impacting demand or that our assessment of demand needs further refinement (including possibly real-world purchase behavior). Alternatively, this finding may suggest that, despite the theoretical prediction, extending the temporal window may reduce consumption independent of changing alcohol reinforcing value. In that case, EFT might affect decision-making pathways other than reinforcement value. For example, EFT may impact motivation to consume without necessarily decreasing the value associated with the reinforcer.\u003c/p\u003e \u003cp\u003eSome limitations are worth noting. First, most of the sample was white, educated, and currently employed, which might limit the generalizability of the results. Second, we observed an increasing proportion of missing data for the daily reports with study progression, which might indicate that the remote monitoring was burdensome and led to decreased compliance with extended participation. This might have been especially true for participants who had to use a study phone, instead of their own phones, for their daily submissions. Additionally, the time windows for breath sample submissions were random and could happen at inconvenient times for the participants. Similarly, the daily cue reminders were sent at fixed times, which could not align with peak craving or drinking time. Thus, whether more robust effects could have been observed with more frequent reminders or self-selected time windows remains unclear. Third, the length of the monitoring phases was contingent on session completion; thus, participant and staff availability for the sessions impacted phase duration. This difference in phase length should not impact the conclusions about changes in consumption, given that consumption analyses accounted for the number of days in each phase. However, it is unclear whether the additional EFT exposure for those with longer phases could have a differential impact on the outcomes. Fourth, our measure of drinks/day was based on self-report. Although we showed a significant association between breath sample results and drink counts, providing biochemical verification of our self-reported data, we recognize that this association does not provide evidence of the accuracy of the number of drinks reported. Thus, direct measures of drinking behavior are recommended in future trials. Additionally, linking the cue exposure more directly to observed drinking behavior could produce more robust effects of EFT on drinking.\u003c/p\u003e \u003cp\u003eAdherence to the intervention could be improved in future studies by using patient-centered approaches in study design, allowing participants to select most convenient/effective monitoring and cue reminder windows, or tailoring these windows based on drinking patterns or ecological momentary assessments of craving. The use of less burdensome biological verification of alcohol use, such as transdermal alcohol sensors, could also decrease barriers to compliance and improve adherence to the intervention. Furthermore, studies are still needed to identify the optimal conditions under which EFT produces generalizable and long-lasting effects. Studies including longer follow-up monitoring and drinking measures post-intervention are also needed to evaluate whether the decrease in drinking is sustained after discontinuation of the daily reminders. Future studies should also include a more diverse population, especially underserved populations that are more largely affected by AUD. This could be achieved, for example, by using targeted recruitment strategies and including individuals with lived experiences in the recruitment and study design team.\u003c/p\u003e \u003cp\u003eOverall, the present findings provide evidence of EFT effectiveness in decreasing discounting and real-world daily drinking. Notably, daily exposure to EFT decreased alcohol consumption in individuals with AUD who had a desire to quit but no immediate plans to enroll in treatment. EFT may be a particularly relevant intervention given its easy implementation with remote delivery, allowing it to be used with hard-to-reach populations\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e and integrated with other therapeutic approaches to augment their effect\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. For example, EFT may be useful as an adjunctive therapy to other digital approaches such as app-based contingency management or cognitive behavioral therapy. EFT may be especially complementary to contingency management approaches, as contingency management is sometimes associated with short-term effects, while the decrease in discounting associated with EFT may lead to longer-term effects. Furthermore, EFT might be more acceptable for non-treatment-seeking individuals, as it does not focus on alcohol specifically. Future studies can continue to inform how EFT can be best tailored to produce the most effective and robust results.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of Interests\u003c/h2\u003e \u003cp\u003eAlthough the following activities/relationships do not create a conflict of interest pertaining to this manuscript, in the interest of full disclosure: Dr. Tegge works on a project supported by Indivior, Inc. Dr. Kablinger\u0026rsquo;s research funding within the last 2 years include: Gilead, Curemark, ALTO, Liva Nova, and BEAM Diagnostics. Dr. MacKillop is a principal and senior scientist in Beam Diagnostics, Inc.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e \u003cp\u003eThis study was supported by the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health (grant number R01AA027381). James MacKillop is supported by the Peter Boris Chair in Addictions Research and a Canada Research Chair in Translational Addiction Research (CRC-2020-00170).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlcohol-Related Emergencies and Deaths in the United States. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics-z/alcohol-facts-and-statistics/alcohol-related-emergencies-and-deaths-united-states#:~\u003c/span\u003e\u003cspan address=\"https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics-z/alcohol-facts-and-statistics/alcohol-related-emergencies-and-deaths-united-states#:~\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e:text=The%20Alcohol%2DRelated%20Disease%20Impact,States%2C%20behind%20tobacco%2C%20poor%20diet.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e2023 NSDUH Detailed Tables. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.samhsa.gov/data/report/2023-nsduh-detailed-tables\u003c/span\u003e\u003cspan address=\"https://www.samhsa.gov/data/report/2023-nsduh-detailed-tables\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eR\u0026ouml;sner, S. \u003cem\u003eet al.\u003c/em\u003e Acamprosate for alcohol dependence. \u003cem\u003eCochrane Database Syst. 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Behav.\u003c/em\u003e 119, 106920 (2021).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"translational-psychiatry","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"tp","sideBox":"Learn more about [Translational Psychiatry](http://www.nature.com/tp/)","snPcode":"41398","submissionUrl":"https://mts-tp.nature.com/cgi-bin/main.plex","title":"Translational Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9182511/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9182511/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEpisodic future thinking (EFT) is a promising intervention for alcohol use disorder (AUD) as it has been shown to decrease delay discounting (DD) and alcohol valuation. In the current randomized controlled trial, we evaluated the effects of EFT on DD, behavioral economic demand, and daily measures of real-world alcohol consumption among individuals with AUD. Sixty-four non-treatment-seeking adults with AUD who wished to reduce or quit drinking but had no immediate treatment plans were randomized to EFT (n\u0026thinsp;=\u0026thinsp;34) or control episodic thinking (CET; n\u0026thinsp;=\u0026thinsp;30). Participants completed four in-laboratory sessions over the course of five weeks, and a follow-up in-laboratory session one month after the completion of the intervention. Additionally, alcohol consumption was monitored remotely for five weeks via a digital app. EFT exposure acutely decreased DD relative to baseline and CET. Additionally, daily exposure to the EFT, but not to CET, decreased the number of drinks/day and the number of drinks/drinking day. Significant changes in behavioral economic demand were not observed. Overall, the present findings suggest that EFT is a promising intervention to decrease alcohol use with effects on real-world alcohol consumption among individuals with alcohol use disorder, but alcohol demand is not a mechanism of this effect.\u003c/p\u003e","manuscriptTitle":"Episodic Future Thinking as an Intervention for Alcohol Use Disorder: \nEffects on Delay Discounting and Real-World Alcohol Consumption","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-03 11:18:15","doi":"10.21203/rs.3.rs-9182511/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"This content is not available.","date":"2026-04-30T18:22:20+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2026-04-25T14:14:09+00:00","index":3,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2026-04-18T17:16:26+00:00","index":3,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2026-04-16T15:42:29+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2026-04-13T12:51:38+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2026-04-10T08:21:01+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2026-03-28T15:59:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-25T17:34:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-25T17:31:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Translational Psychiatry","date":"2026-03-23T17:18:26+00:00","index":"","fulltext":""},{"type":"checksFailed","content":"","date":"2026-03-23T16:58:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"translational-psychiatry","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"tp","sideBox":"Learn more about [Translational Psychiatry](http://www.nature.com/tp/)","snPcode":"41398","submissionUrl":"https://mts-tp.nature.com/cgi-bin/main.plex","title":"Translational Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c67a82c2-8138-47f8-b15a-a386df2a821f","owner":[],"postedDate":"April 3rd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"This content is not available.","date":"2026-04-30T18:22:20+00:00","index":2,"fulltext":"This content is not available."}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":65317155,"name":"Health sciences/Diseases/Psychiatric disorders/Addiction"},{"id":65317156,"name":"Biological sciences/Psychology/Human behaviour"},{"id":65317157,"name":"Biological sciences/Neuroscience/Learning and memory"}],"tags":[],"updatedAt":"2026-04-03T11:18:16+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-03 11:18:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9182511","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9182511","identity":"rs-9182511","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}