Exploring the effects of attachment dimensions on nicotine-induced attentional bias: an eye-tracking observational study in young people who smoke

Introduction: Tobacco use disorder (TUD) is shaped by pharmacological and neuropsychological mechanisms, with growing evidence implicating attachment strategies and emotion regulation in its onset and maintenance. A hallmark of TUD is attentional bias (AB), in which smoking-related cues disproportionately capture attention, indicating alterations in cognitive control processes. However, research on AB in TUD has largely overlooked the role of attachment strategies. Methods: In this observational case–control study, 110 healthy Italian university students (62 people who smoke, 48 partici- pants who do not smoke) completed the Fagerström Test for Nicotine Dependence and the Attachment Style Questionnaire and performed an eye-tracking task. Each trial presented a prime image (neutral or threatening), followed by a choice between smoking- and care-related images displayed side by side. AB indices included relative fixation time, fixation count, and gaze points. Results: People who smoke exhibited reduced AB toward care cues regardless of emotional priming, with no prime-related changes in gaze behavior. AB indices for care- and smoking-related images were determined by smoking status rather than the preceding image. Regression analyses showed that avoidant and dismissing attachment styles significantly predicted AB indices, along with group status. Among people who smoke, nicotine dependence predicted relative fixation time only. Conclusions: AB toward smoking cues is influenced not only by smoking status but also by individual attachment patterns. These findings support evidence that attention and choice can dissociate: primes may affect decisions without altering gaze. The results highlight the importance of integrating socio-affective factors into research on drug-related AB. Implications: This study introduces a novel eye-tracking paradigm that contrasts smoking-related cues with care related (rather than neutral) stimuli,offering amore ecologically valid approach to investigating attentional bias in peoplewhosmoke. By priming participants with emotionally valenced images and analyzing gaze patterns across competing salient stimuli, we demonstrate that attentional bias is modulated not only by nicotine dependence but also by individual differences in attachment-related constructs. These findings underscore the relevance of socio-affective factors in addiction research and support the utility of emotion- and attachment-sensitive protocols for uncovering the complex mechanisms underlying cue reactivity in addiction.