Crushing Virtual Cigarettes Reduces Tobacco Addiction and … · 2013. 12. 6. · ORIGINAL ARTICLE...

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ORIGINAL ARTICLE Crushing Virtual Cigarettes Reduces Tobacco Addiction and Treatment Discontinuation Benoit Girard, M.D., 1 Vincent Turcotte, Tech., 1 Ste ´ phane Bouchard, Ph.D., 2 and Bruno Girard, M.B.A. 1 Abstract Pilot studies revealed promising results regarding crushing virtual cigarettes to reduce tobacco addiction. In this study, 91 regular smokers were randomly assigned to two treatment conditions that differ only by the action performed in the virtual environment: crushing virtual cigarettes or grasping virtual balls. All participants also received minimal psychosocial support from nurses during each of 12 visits to the clinic. An affordable virtual reality system was used (eMagin HMD) with a virtual environment created by modifying a 3D game. Results revealed that crushing virtual cigarettes during 4 weekly sessions led to a statistically significant reduction in nicotine addiction (assessed with the Fagerstro ¨ m test), abstinence rate (confirmed with exhaled carbon mon- oxide), and drop-out rate from the 12-week psychosocial minimal-support treatment program. Increased re- tention in the program is discussed as a potential explanation for treatment success, and hypotheses are raised about self-efficacy, motivation, and learning. Introduction T obacco use creates a triple addiction: physical, psycho- logical, and social. Epidemiologic data suggest that more than 45% of smokers in the United States try to quit smoking each year, with limited success. 1 The interaction among mul- tiple factors that cause and maintain the addiction makes quitting very complex. 2 Although several pharmacological, cognitive-behavioral, and motivational options have been proposed, 3–5 more effective and innovative treatments are needed because traditional therapeutic methods listed and evaluated by the Agency for Healthcare Research and Quality 3 and the World Health Organization 6 still need to be improved. Virtual reality (VR) is a useful tool in addiction research and treatment. For example, Bornick et al. 7 immersed smok- ers in a virtual environment containing stimuli associated with urges to smoke, such as burning cigarettes, cigarette packs, and people offering cigarettes. They showed that when compared to a virtual environment without smoking cues, such as an empty underwater room, participants reported a statistically significant increase in cravings as measured with self-report. Lee et al. 8 compared the response to smoking cues while immersed in VR versus being exposed to still images of the same 3D stimuli. They found that immersion in an in- teractive and real-time 3D virtual environment significantly increased craving compared to still images. Since the two studies used participants who were not deprived of nicotine prior to the cue-reactivity tests, Bauman and Sayette 9 per- formed a cue-exposure experiment with participants who had been deprived of nicotine for 12 hours. Even if their stimuli were presented on a computer monitor instead of a head-mounted display, they still found a significant increase in urges to smoke. More recently, Carter et al. 10 examined the craving experience of young adult smokers while immersed in VR. They found that virtual smoking cues elicit the types of reasons to smoke, including positive outcome expectancies associated with smoking (e.g., things would be better if I smoke right now) and amelioration of negative affective states (e.g., I feel depressed). Cue-reactivity studies have shown that drug-related stimuli can also elicit strong craving reactions, 11 but the effi- cacy of treatment based exclusively on exposure to drug-re- lated cues appears to be limited. 12 Inconsistent evidence for the effectiveness of cue-exposure therapy may be explained by a need to better integrate this form of treatment with recent theoretical findings on learning. 12 However, VR may help in providing ecologically valid contexts that would make cue exposure more effective. 9 The use of cue-exposure therapy using VR is still in its infancy. 13,14 Participants’ level of pres- ence (the impression of being there in the virtual environ- ment) and cybersickness (virtual reality–induced side effects) 1 GRAP, Occupational Psychology Clinic, Saguenay, Que ´bec, Canada. 2 Department of Psychology, Universite ´ du Que ´bec en Outaouais, Que ´bec, Canada. CYBERPSYCHOLOGY &BEHAVIOR Volume 12, Number 5, 2009 ª Mary Ann Liebert, Inc. DOI: 10.1089=cpb.2009.0118 477

Transcript of Crushing Virtual Cigarettes Reduces Tobacco Addiction and … · 2013. 12. 6. · ORIGINAL ARTICLE...

Page 1: Crushing Virtual Cigarettes Reduces Tobacco Addiction and … · 2013. 12. 6. · ORIGINAL ARTICLE Crushing Virtual Cigarettes Reduces Tobacco Addiction and Treatment Discontinuation

ORIGINAL ARTICLE

Crushing Virtual Cigarettes Reduces Tobacco Addictionand Treatment Discontinuation

Benoit Girard, M.D.,1 Vincent Turcotte, Tech.,1 Stephane Bouchard, Ph.D.,2 and Bruno Girard, M.B.A.1

Abstract

Pilot studies revealed promising results regarding crushing virtual cigarettes to reduce tobacco addiction. In thisstudy, 91 regular smokers were randomly assigned to two treatment conditions that differ only by the actionperformed in the virtual environment: crushing virtual cigarettes or grasping virtual balls. All participants alsoreceived minimal psychosocial support from nurses during each of 12 visits to the clinic. An affordable virtualreality system was used (eMagin HMD) with a virtual environment created by modifying a 3D game. Resultsrevealed that crushing virtual cigarettes during 4 weekly sessions led to a statistically significant reduction innicotine addiction (assessed with the Fagerstrom test), abstinence rate (confirmed with exhaled carbon mon-oxide), and drop-out rate from the 12-week psychosocial minimal-support treatment program. Increased re-tention in the program is discussed as a potential explanation for treatment success, and hypotheses are raisedabout self-efficacy, motivation, and learning.

Introduction

Tobacco use creates a triple addiction: physical, psycho-logical, and social. Epidemiologic data suggest that more

than 45% of smokers in the United States try to quit smokingeach year, with limited success.1 The interaction among mul-tiple factors that cause and maintain the addiction makesquitting very complex.2 Although several pharmacological,cognitive-behavioral, and motivational options have beenproposed,3–5 more effective and innovative treatments areneeded because traditional therapeutic methods listed andevaluated by the Agency for Healthcare Research andQuality3 and the World Health Organization6 still need to beimproved.

Virtual reality (VR) is a useful tool in addiction researchand treatment. For example, Bornick et al.7 immersed smok-ers in a virtual environment containing stimuli associatedwith urges to smoke, such as burning cigarettes, cigarettepacks, and people offering cigarettes. They showed that whencompared to a virtual environment without smoking cues,such as an empty underwater room, participants reported astatistically significant increase in cravings as measured withself-report. Lee et al.8 compared the response to smoking cueswhile immersed in VR versus being exposed to still images ofthe same 3D stimuli. They found that immersion in an in-teractive and real-time 3D virtual environment significantly

increased craving compared to still images. Since the twostudies used participants who were not deprived of nicotineprior to the cue-reactivity tests, Bauman and Sayette9 per-formed a cue-exposure experiment with participants whohad been deprived of nicotine for 12 hours. Even if theirstimuli were presented on a computer monitor instead of ahead-mounted display, they still found a significant increasein urges to smoke. More recently, Carter et al.10 examined thecraving experience of young adult smokers while immersedin VR. They found that virtual smoking cues elicit the types ofreasons to smoke, including positive outcome expectanciesassociated with smoking (e.g., things would be better if Ismoke right now) and amelioration of negative affectivestates (e.g., I feel depressed).

Cue-reactivity studies have shown that drug-relatedstimuli can also elicit strong craving reactions,11 but the effi-cacy of treatment based exclusively on exposure to drug-re-lated cues appears to be limited.12 Inconsistent evidence forthe effectiveness of cue-exposure therapy may be explainedby a need to better integrate this form of treatment with recenttheoretical findings on learning.12 However, VR may help inproviding ecologically valid contexts that would make cueexposure more effective.9 The use of cue-exposure therapyusing VR is still in its infancy.13,14 Participants’ level of pres-ence (the impression of being there in the virtual environ-ment) and cybersickness (virtual reality–induced side effects)

1GRAP, Occupational Psychology Clinic, Saguenay, Quebec, Canada.2Department of Psychology, Universite du Quebec en Outaouais, Quebec, Canada.

CYBERPSYCHOLOGY & BEHAVIOR

Volume 12, Number 5, 2009ª Mary Ann Liebert, Inc.DOI: 10.1089=cpb.2009.0118

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were found to be acceptable,13 and functional magnetic res-onance imaging data show that expected brain areas are re-cruited during the immersion and treatment.14

One significant challenge for effective treatments is drop-out, since treatment continuation is a significant predictor ofits effectiveness.15–19 Based on preliminary data from 16smokers treated in an open trial in our clinic,20 the action ofcrushing cigarettes in VR may have an impact on the be-haviors and motivation of smokers undergoing therapy. Weproposed that adding crushing virtual cigarettes to a psy-chosocial treatment program could have a synergistic effectand significantly increase the effectiveness of the psychoso-cial program.

The objective of this study is to test the advantages ofcombining cybertherapy (four sessions during which thepatient crushes virtual cigarettes) to a psychosocial smoking-cessation treatment program for adults. The participants wereassigned randomly to one of two conditions: (a) Balls, wheregrasping balls (control group) in VR was combined with thepsychosocial program; and (b) Cigarettes, where crushingcigarettes (experimental group) in VR was combined with thepsychosocial program.

Method

Sample

The sample was recruited from the general populationthrough ads in local medias. After they called the GRAPclinic, participants were contacted by telephone to see whe-ther they met the selection criteria, then seen individually toinform them of the details of their participation in the study.They were also informed about VR and the potential sideeffects. After completing the consent form, participants wereseen individually by a nurse to complete a sociodemographicquestionnaire describing their tobacco consumption and toundergo a brief medical examination. They also completedthe questionnaires described below and a first exhaled carbonmonoxide test. Participants were then told to which of thetwo experimental groups they had been randomly assignedto. Finally, they tried out a virtual environment (differentfrom the one used in treatment) to familiarize themselveswith VR and with how to ‘‘walk’’ in the virtual environment.No target date for stopping was fixed.

The following selection criteria were applied: (a) beingbetween 18 and 65 years old, (b) being in good general health,and (c) regularly consuming 10 cigarettes or more dailyduring the last year. The following exclusion criteria werealso applied and were sufficient for rejection: (a) treatment fora mental health problem during the last year (e.g., majordepression, panic disorder, psychosis, bipolar affective dis-order, anorexia, bulimia), (b) regular ingestion of a medica-tion affecting the central nervous system, (c) a positive historyof alcoholism or severe drug addiction during the last year,(d) a body mass index (BMI) below 15 kg=m2 (anorexia) orabove 40 kg=m2 (obesity class III), (e) one or more periods ofabstinence from cigarettes of more than 3 months during thelast year, (f) previous attempt to stop smoking in the last 6months, (g) serious illness during the last 6 months, and (h)use of smoking-cessation products (e.g., gum, patch, bupro-pion, varenicline) during the last 6 months.

The sample at the start of the study consisted of 91 par-ticipants, 45 assigned randomly to the Balls condition and 46

to the Cigarettes condition. The average age was 44 years(SD¼ 11 years), and the participants had been smoking for anaverage of 27 years (SD¼ 12 years). Forty-five percentsmoked more than 21 cigarettes a day. Fifty-seven percentwere women, and 68% were employed. Statistical analysescomparing the two conditions on these sociodemographicparameters did not find any significant difference.

Procedure

Participants came to the clinic once a week for the first 4weeks, then once every 2 weeks for the second and thirdmonths of the study. The psychosocial program and datacollection took place in weeks 1, 2, 3, 4, 6, 8, 10, and 12. Eachsession included 30 minutes with a nurse, who took their vitalsigns (blood pressure, pulse, weight), collected the smoker’sjournal, administered the questionnaires, performed carbonmonoxide testing, discussed with the participant any per-sonal conflicts related to smoking cessation, and provided abrief counseling session and support in the application of aFrench self-help program (English title of the program: On theRoad to Quitting: Guide to Becoming a Non-Smoker).21

Participants also took part in one VR session per weekduring the first 4 weeks=visits of the treatment. All were ex-posed to VR for 30 minutes in each session. In the virtualenvironment, the participants were asked, depending onwhich experimental condition they were in, to either find andcrush up to 60 virtual cigarettes (active treatment in VR) orgrasp up to 60 virtual balls (control placebo condition in VR).

A 6-month follow-up was conducted by phone. Partici-pants were asked to state whether or not they had smoked inthe last week, how many cigarettes were smoked, and if theyhad flashback memories of the virtual environment.

Equipment

The virtual environment was displayed on an eMagin Z800head-mounted display (with built-in 3-dof motion tracker)using a Pentium IV computer (3.2 GHz, 1 GB of RAM) run-ning on Windows XP and an nVidia 7300GS video card withstereoscopy.

The virtual environment consists of a map created usingthe game engine Unreal 2�. It represents a fictional medievalcastle with several indoor rooms and outdoor areas withvaried materials, lights, and sounds. XSI from Softimage�was used to design the virtual arm and to integrated it withcigarettes and balls in the 3D environment (see Fig. 1). For-ward and backward motion in the virtual environment andthe action of the virtual arm were controlled with a Logitechwireless gamepad.

Measures: main outcome variables

Fagerstrom test for nicotine dependence22. Nicotineaddiction was estimated using the revised version of the Fa-gerstrom,14 which includes six items and provides a globalscore ranging from 0, no addiction, to 10, high level of addiction.It measures significant signs of nicotine addiction, such as thetime before smoking the first cigarette of the day and thefrequency of smoking. This instrument was administeredbefore the start of the first week of therapy (start of treat-ment), at the fourth week of therapy (end of the virtual realityphase), and at the twelfth week (end of the program).

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Daily smoker’s journal and exhaled carbon monoxide.The abstinence rate was measured on the basis of the smok-er’s journal (daily self-reported measurement of the numberof cigarettes per day) and confirmed by an exhaled carbonmonoxide test as measured at the fourth and last sessions ofthe program. A stringent cutoff score on the carbon monoxidetest was set at 6 parts per million to confirm abstinence in thelast week reported in the smoker’s journal.

Drop out. The drop-out rate was defined as follows:participants who stopped coming to the psychosocial pro-gram sessions, no matter the reason evoked by the partici-pant, including moving to another city, having reached his orher own therapeutic objectives, or using a smoking-cessationproduct listed in the selection criteria. The number of par-ticipants who dropped out of the program was measuredeach week.

Measures: predictors and side effects variables

Two variables were used in multiple regressions analyses:urges to smoke and the feeling of presence. Virtual realityinduced side effects were also assessed.

Questionnaire of Smoking Urges—Brief (QSU-Brief)23,24.The QSU-Brief assesses actual urges to smoke in the presenceof positive and negative reinforcements. It is built on twofactors, the intention to smoke (approach motivation) and theanticipation of relief of negative affect (avoidance motiva-tion), but only the total score is reported here. The shortversion, in French, has 10 items, rated on a scale of 1, totallydisagree, to 7, totally agree, and the score obtained at the firsttherapy session was used in a statistical regression analysis tocontrol the severity of smoking problems in predictingtreatment drop-out.

Presence Questionnaire (PQ)25. The PQ uses a 7-pointLikert scale (1, not at all, to 7, completely) to measure dimen-sions of presence. We used an adapted version for a Frenchsample,26,27 and its factor structure consists of six factors:realism (extent to which virtual environments look natural),affordance to act (active exploration and control of events),quality of the interface (delay or awkwardness related to theapparatus), ability to examine (observing objects from dif-ferent angles), self-evaluation of performance (feeling ofcompetence and adaptation with respect to the execution oftasks), and auditory and tactile cues (ability to touch certainobjects). Participants completed this instrument at the end ofeach immersion in VR, and the average of the total presencescores for each VR session was used in a statistical regressionanalysis to control for presence in predicting treatment out-come.

Simulator Sickness Questionnaire (SSQ)28. The SSQcontains 16 items measuring on a 4-point scale (0, not at all, to3, severely) the degree of discomfort felt by the individual(nausea, vertigo, tired eyes, etc.). Our adaptation for a Frenchsample29 has two dimensions: nausea and oculomotor prob-lems. Participants completed this instrument at the end ofeach VR immersion to document potential side effects (cy-bersickness).

Results

In planning the statistical design of this study, it was de-cided to use the intent-to-treat principle; that is, the results ofall the participants were analyzed, whether or not someparticipants dropped out of treatment. This approach isconsidered to be more conservative because it tends to de-crease the effect of a treatment by carrying forward to thedifferent measurement times the negative scores of patients

FIG. 1. Screenshot of the virtual arm extending to pick up and crush a virtual cigarette.

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who dropped out30–32 and is not based exclusively on thepeople who had the most chance of benefiting from thetreatment. For intention-to-treat analyses, the last data ob-tained from participants who stopped participating in theprogram, for any reason, was carried forward to all subse-quent measurements.

The mean number of virtual stimuli (cigarettes or balls)picked up during each session (between 33 and 46) was notsignificantly different between the two conditions: group ef-fect, F(1, 57)¼ 0.49, ns; time–condition interaction, F(3,171)¼ 0.27, ns. However, it increased significantly over thecourse of the treatment: time effect, F(3, 171)¼ 88.16,p< 0.001.

The program’s impact on the Fagerstrom measure of nic-otine addiction (see Table 1) was tested using a repeatedmeasures ANOVA with three measurement times (pretreat-ment, end of the VR sessions, end of the program). The resultsrevealed significant differences in the time, F(2, 178)¼ 33.07,p< 0.001; condition, F(1, 89)¼ 4.69, p< 0.025; and time=condition interaction, F(2, 178)¼ 3.75, p< 0.05, effects. Theseanalyses showed that the treatment program significantlyreduced nicotine addiction and that crushing cigarettes in VRhad a significantly better impact than grasping balls. Thecontrast analysis showed that the impact of the program be-gan to be felt by the fourth week, F(1, 89)¼ 33.34, p< 0.001,and continued until the end, F(1, 89)¼ 55.18, p< 0.001. Thecontrast analysis showed, however, that the specific advan-tage of crushing cigarettes instead of grasping balls becamesignificant only between week 4 and the end of the treatment,F(1, 89)¼ 6.87, p< 0.01.

The percentage of abstinence was tested using a chi-squaretest on the intention-to-treat data. After the fourth week, 2%of participants in the Balls condition and 9% in the Cigarettescondition were abstinent. This difference was not signifi-cant: w2(1)¼ 1.84, ns. On the other hand, the rate of absti-nence reached 15% in the twelfth week for participantscrushing virtual cigarettes, as opposed to 2% for partici-pants in the placebo virtual condition who were graspingballs. This difference was statistically significant: w2(1)¼ 4.79,p< 0.05.

At the 6-month telephone follow-up, 39% of the partici-pants in the Cigarettes condition stated they had not smoke inthe last week, as opposed to 20% in the Balls condition:w2(1)¼ 4.05, p< 0.05. The mean number of cigarettes theyrecalled smoking in the last week was 8.4 in the Cigarettescondition and 15.5 in the control condition: t(89)¼ 3.13,p< 0.01. Also, 23% of the participants in the experimentalcondition reported having had flashback memories ofcrushing cigarettes in the virtual environment, as opposed to3% in the control condition: w2(1)¼ 7.34, p< 0.01.

The drop-out rate was measured each week (see Fig. 2),and a survival analysis applied to the overall comparison ofthe two groups’ retention curves showed that the retentionprofile differed significantly between the two conditions:Gehan’s Wilcoxon test (1)¼ 6.96, p< 0.01. On average, par-ticipants in the control condition dropped out of the programafter 5.89 weeks (SD¼ 4.66), and those crushing virtual cig-arettes dropped out on average after 8.26 weeks (SD¼ 4.17),which is significantly later: t(89)¼ 2.56, p< 0.025. Overall, itsuggests that participants in the control condition still com-

Table 1. Descriptive Data on the Fagerstrom Test for Nicotine Dependence (N¼ 91)

Grasping virtual ballscondition Mean (SD)

Crushing virtual cigarettescondition Mean (SD)

Week 1 (baseline) 6.36 (1.97) 5.91 (1.60)Week 4 (end of virtual treatment) 5.47 (2.56) 4.48 (2.90)Week 12 (end of psychosocial treatment) 5.38 (2.55) 3.87 (2.62)

FIG. 2. Number of participants remaining in the program (N¼ 91).

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pleted the four placebo VR immersions and that the impact ofcrushing virtual cigarettes on retention in the program man-ifested itself later on during the treatment. However, chi-square tests revealed that significantly more controls haddropped out of treatment at week 4 (22% vs 49%), w2(1)¼ 7.35,p< 0.001, and week 12 (50% vs 71%), w2(1)¼ 4.24, p< 0.05.

Interestingly, participants who stayed in the psychosocialtreatment program until the end had been smoking for alonger period of time than those who dropped out: 29.8 years,SD¼ 11.8 vs 24.2 years, SD¼ 12.5; t(89)¼ 2.04, p< 0.05. Todocument the relative impact of crushing cigarettes in VR, weperformed a logistic multiple regression analysis to predictwho would or would not stay in the program until the end(week 12). The data gathered the first week was used for threepredictors: the total score on the QSU-brief, the number ofyears the participants had smoked, and the experimentalcondition to which participants were assigned to. The re-gression equation explained a significant percentage of casesthat remained in the program: 65%, w2(3)¼ 8.1, p< 0.05. Therespective contributions of the three predictors were signifi-cant only for the variable experimental condition, b¼�0.92,Wald (1)¼ 4.08, p< 0.05, suggesting that whether or not onecrushes cigarettes in VR is more important in predicting re-tention in the program than severity of smoking urges,b¼�0.001, Wald (1)¼ 0.005, ns, or duration of the smokingproblem, b¼ 0.04, Wald (1)¼ 3.33, ns.

Table 2 shows the scores measuring presence obtainedduring the four VR immersions. A repeated measures AN-OVA did not detect any significant difference between thetwo conditions: condition effect F(1, 55)¼ 0.01, ns; interactionF(3, 165)¼ 0.36, ns. But a significant time effect over the foursessions, F(3, 165)¼ 4.08, p¼ 0.01, showed that presence in-creased significantly with practice.

A multiple regression analysis was used to examine therole of presence (averaged over the four sessions) on theimpact of the intervention program on the Fagerstrom test(utilizing presence and residualized change scores to measurechange on the outcome measure).33 The multiple regressionwas significant, F(2, 90)¼ 39.78, p< 0.001, and showed thatpresence contributes significantly to changes in scores mea-suring tobacco addiction, semipartial correlation (sr)2¼�0.18,p< 0.025).

Finally, VR-induced side effects were measured after eachtherapy session (see Table 3). The repeated measures ANO-VA showed that participants crushing cigarettes in VR feltsignificantly more cybersickness, F(1, 57)¼ 4.10, p< 0.05, andthat this effect diminished over time, F(1, 171)¼ 2.92, p< 0.05,in a similar fashion in both conditions, interaction F(3,171)¼ 1.90, ns.

Conclusion

This study shows a significant impact of crushing ciga-rettes in VR on three variables: nicotine addiction, rate ofabstinence, and retention of patients in the psychosocialtreatment program. Results appear to hold at follow-up, al-though measurement was performed differently at post-treatment and follow-up. Presence seems to be associatedwith the beneficial effect of the program, and cybersickness ismore frequent among participants in the experimental con-dition.

The mechanism explaining our findings remains unclearand deserves further study. The first explanation that comesto mind may have less to do with behavior change and morewith retention in the counseling and self-help program.Crushing virtual cigarettes may have made patients morewilling to come to their regular meetings with the nurse, andcontinuation of treatment being an important predictor ofoutcome,16–19 the impact of the cybertherapy may be limitedto foster treatment attendance and adherence. Enjoyingcrushing virtual cigarettes would only be a motivator, and theactive ingredients in the treatment would remain those re-lated to counseling and applying self-help strategies. If this isthe case, it would still be interesting to test the benefits ofadding crushing virtual cigarettes to more powerful smok-ing-cessation treatment, such as cognitive-behavior therapyor pharmacotherapy (e.g., patches, varenicline, rimonabant)or new approaches.7,13,19

However the impact of crushing virtual cigarettes isprobably more complex than only motivating patients to at-tend to their appointments. Its impact could hardly be limitedto the VR experience alone, since participants who graspedvirtual balls were also immersed in the same virtual envi-ronment. At least four additional potential explanations canbe formulated, and the first two fall under factors associatedwith beliefs and self-regulation. First, successfully crushingvirtual cigarettes may increase perceived self-efficacy toperform behaviors associated with smoking cessation. Ban-dura has shown repeatedly that people’s confidence in theirability to perform a behavior is a strong predictor of theemission of such behavior.34 The contribution of self-efficacyis also important in the treatment of tobacco addiction.35–37

Perceived self-efficacy to quit smoking might be increased byseeing oneself succeeding in crushing cigarettes and investingefforts in finding more cigarettes to crush.

Another hypothesis related to self-regulation could be apositive impact on motivation to quit smoking. Investingtime and effort to crush virtual cigarettes, as well as enjoyingtheir success in crushing cigarettes, might boost people’smotivation to quit smoking. Motivation, and especially

Table 3. Descriptive Data on Simulator

Sickness (N¼ 91)

Grasping virtualballs condition

Mean (SD)

Crushing virtualcigarettes condition

Mean (SD)

Week 1 39.39 (48.72) 81.93 (70.11)Week 2 41.62 (42.45) 58.91 (55.57)Week 3 41.77 (44.01) 51.91 (45.53)Week 4 28.67 (41.47) 51.24 (62.55)

Table 2. Presence during Immersion in Virtual

Reality (N¼ 91)

Grasping virtualballs condition

Mean (SD)

Crushing virtualcigarettes condition

Mean (SD)

Week 1 121.44 (19.59) 119.09 (19.64)Week 2 124.00 (21.65) 125.74 (26.81)Week 3 125.65 (19.00) 126.71 (20.48)Week 4 127.04 (19.24) 128.77 (22.73)

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stage of changes, are factors associated with treatment out-come.38–40 It may be important to note that perceived self-efficacy and motivation contribute differently to behaviorchange, although they are both related concepts. Holdingstrong self-beliefs of capabilities to perform a behavior doesnot mean that someone will actually engage in behavioralchanges. Crushing virtual cigarettes not only may help peo-ple believe they can do it but also may give them a strongerdrive to keep doing it.

Conditioning models of addictions41,42 could offer twoadditional alternative explanations. One hypothesis could bethat the task performed in VR helped our participants prac-tice the automatic response to crush cigarettes through in-tensive repeated experiences. Seeing smoking cigarettes in a3D environment is a cue known to elicit urges to smoke.43 Butcrushing cigarettes with a virtual arm is quite different andcould be seen as a sensorimotor stimulus or an action-cueexposure. Perceiving oneself in an embodied experience44 ofrepeatedly crushing cigarettes could facilitate the automati-zation of a new conditioned response. However, since thetask performed in VR did not require actual motor behaviorof the arm and hand to crush the virtual cigarettes, the ad-vantage of VR over visualization might be that it is morepowerful, and the therapist can confirm that the patient isreally engaged in crushing the cigarettes.

The second explanation, derived from learning and con-ditioning models, focuses on the association between positivemood and behaviors associated with smoking cessation. For aperson addicted to tobacco, seeing smoking-related stimulielicits a conditioned response that triggers the desire tosmoke and the affective, cognitive, and motor responses as-sociated with smoking. It has been shown that similarmechanisms occur with cue exposure to virtual stimuli.7,14,43

Experiencing these conditioned responses can be frustratingfor someone who wants to quit smoking. Having fun playinga game in which one finds and crushes cigarettes could createa more positive emotional response than frustration to seeingand expecting conditioned stimuli. In this case, what wouldbe conditioned in VR is not a new behavior but a mood thatfacilitates smoking cessation. Since enjoyment with the gamehas not been systematically measured, but only observed bythe experimenters, this hypothesis is only tentative.

It may be possible that some or all of the five potentialexplanations interact with each other. Experimental manip-ulations could also be planned to test which of these hy-potheses are most plausible. It would be interesting tomeasure self-efficacy and motivation in a study comparingthe impact of crushing real cigarettes to virtual ones. Ex-periments addressing the learning and conditioning hy-potheses could compare (a) crushing virtual cigarettesdepicted with high and low visual realism, (b) performingcrushing behavior with and without a virtual arm and handtracking the physical arm with 6-dof trackers or motioncapture systems, or (c) using strong and weak reinforcers tomanipulate emotions associated with crushing the virtualstimuli. Assessing perceived self-efficacy, motivation to quitsmoking, motivation to come to counseling sessions, andstages of change during an outcome trial would also be im-portant. Even if the exact mechanism involved still eludes ussomewhat, one fact remains: crushing cigarettes in a 3D en-vironment with a virtual arm led to decreased nicotine de-pendence and increased retention of patients in treatment. It

is hoped that our study will stir new interest in the field ofaddiction by opening a new avenue in addition to cue ex-posure.13

Disclosure Statement

Conflict of interests exist. This project was funded inter-nally by the G.R.A.P. Clinic. The software may be released asa commercial product at some point. This clinical trial hasbeen registered under the number NCT00639093.

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Address correspondence to:Dr. Benoit Girard, M.D.

GRAP, Clinique de Psychologie au Travail3750 Boul. du Royaume, Suite 205

Ville de Saguenay, Arr. JonquiereQuebec, G7X 0A4

Canada

E-mail: [email protected]: www.grap.ca

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