Go up in smoke: proof of concept study on tobacco craving in a VR environment

Background: Recent technological developments in virtual reality (VR) provide a potential to reduce the burden of tobacco addiction. Despite efforts to reduce smoking initiation and to increase smoking cessation, still approximately 19.2% of female and 25.7% of male adults in the Netherlands smoke. Recent research indicates even higher prevalence rates in vulnerable groups, such as individuals with intellectual disability, mental illness, or low socio-economic status. One of the factors in the persistence of tobacco related disorders, is that smoking cessation programs are only successful in about 10-16% of patients. Moreover, existing treatments may not be suitable for vulnerable groups, which might hinder uptake and effectiveness. Several studies in the area of VR have assessed the potential to evoke craving as part of cue-reactivity. However, research on cue-exposure therapy, which is based on the extinction of a conditioned response, reports only limited effects. Thus, teaching coping strategies in VR that are related to real-life situations, might be a potential approach for behavior change, especially in groups that barely benefit of existing cessation programs.
Methods: This research comprises two evaluations with each three iterations as part of a user-centered development approach. Recruited participants were heavy smokers (Fagerström >= 5) from three Dutch healthcare institutions, involving individuals with intellectual disability, mental illness, and pulmonal issues. The first part of participants derived from every subgroup participated (1) to improve the cue-reactivity environment, procedure and related measurements. The other part applied (2) virtual coping strategies after being exposed to the previously improved cue-reactivity environment to explore and refine possibilities for craving reduction. Self-reported data (VAS, QSU-Brief), psychophysiological measures (GSR, HR), and eye-tracking were used as a potential continuous measurement of craving. Moreover, the think-aloud protocol was employed to improve the user’s experience based on the cognitive insights.
Findings: Twenty-three participants participated in the first study group to improve the cue-reactivity and related measurements within the virtual environment. Preliminary results indicate a significantly increased level of craving after exposure compared to baseline. Participants in all subgroups successfully managed to use the VR-application while an increasing age revealed more problems in handling controls. Smoking-related cues and contexts were rated highly individually due to personal habits. The incorporated multimodal interactions involving smell, sound, and haptics have been identified to be important factors that influence cravings. Moreover, social influences and emotional distress have been reported to influence the urge to smoke. To continuously monitor craving levels in vulnerable groups, eye-tracking has been reported unfeasible due to complicate calibration procedures. Furthermore, motion artifacts and uncontrollable contextual variables might bias the measurement of galvanic skin responses.
Discussion: The preliminary results are in line with the previous research in the field of VR cue-reactivity by showing significant increases in craving within the subgroup of vulnerable individuals. The iterative development approach indicates a need for highly personalizable environments with complex multimodal cues, that involve social interactions and affective influences. Future research should investigate the potential of coping skills training by providing scientifically validated relaxation and distraction exercises.
Acknowledgement: This work is supported by the Pioneers in Health Care project GoUpInSmoke. The authors gratefully acknowledge the contribution of Sytze Sicco Smit, Christa ten Bolscher, Saskia van Horsen, and all our participants.