|Year : 2022 | Volume
| Issue : 1 | Page : 16-21
Suitability of virtual reality for simulating smoking among current mild cigarette smokers in Chennai city
Monica Gurupriya Mohanram, PD Madankumar
Department of Public Health Dentistry, Ragas Dental College, Chennai, Tamil Nadu, India
|Date of Submission||24-May-2021|
|Date of Acceptance||05-Jul-2021|
|Date of Web Publication||04-Jan-2022|
Monica Gurupriya Mohanram
Ragas Dental College, 2/102, SH49, Uthandi, Chennai - 600 119, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Multi-component psychological interventions have proven broadly to be effective for smoking cessation. Cue-induced craving is considered responsible for relapse after smoking cessation. Cue Exposure Therapy (CET) consists of controlled and repeated exposure to stimuli associated with substance use to extinguish craving responses. A recent mode of cue presentation that has received increasing attention in the literature is the use of virtual reality (VR). VR uses computer-based technology to generate three-dimensional environment that allows people to move through their surroundings and interact with the created environment. The aim of our study was to determine the suitability of VR for simulating smoking among current cigarette smokers in Chennai city.
Materials and Methods: A cross-sectional study was conducted with a purposive sample of 40 truck drivers above 18 years of age. Sense of satisfaction experienced by participants after completion of one VR session was assessed at the end of the experiment using suitability evaluation questionnaire (SEQ).
Results: The mean age of the participants was 47.23 ± 12.43 ranging from 19 to 74 years. The suitability of VR for simulating smoking among current mild cigarette smokers according to the SEQ scale showed intermediate suitability.
Conclusions: The result of the present study showed that VR environments that simulate real situations are suitable to elicit craving and thus assist in smoking cessation.
Keywords: Addiction, cessation, methodology, relapse prevention
|How to cite this article:|
Mohanram MG, Madankumar P D. Suitability of virtual reality for simulating smoking among current mild cigarette smokers in Chennai city. J Oral Res Rev 2022;14:16-21
|How to cite this URL:|
Mohanram MG, Madankumar P D. Suitability of virtual reality for simulating smoking among current mild cigarette smokers in Chennai city. J Oral Res Rev [serial online] 2022 [cited 2022 Jan 28];14:16-21. Available from: https://www.jorr.org/text.asp?2022/14/1/16/334828
| Introduction|| |
Tobacco Control Policy India Project Report revealed that about 275 million tobacco users are present in India. Tobacco use is responsible for nearly half of all cancers among males and one-quarter of all cancers among females. Unless and until urgent action is taken, by 2020, tobacco consumption could cause more than 1.5 million deaths in India annually. The Global Adult Tobacco Survey (GATS) 2 report showed that every tenth adult in India smokes tobacco-11.9% in rural areas and 8.3% in urban areas. The prevalence of smoking among men is 19.0%, while among women the figure is 2.0%.
Bidi is the most popular form of smoking tobacco used in India, especially in rural areas, and cigarette is the second-most popular form of smoking tobacco, mainly used in urban areas. Although the cigarette smoke has many harmful chemicals such as nicotine, cotinine, tar, hydrogen cyanide, tobacco-specific nitrosamines, carbon monoxide, and polycyclic aromatic hydrocarbons; nicotine is the one most often associated with dependence. The nicotine in the cigarette is psychoactive and causes neuroadaptation leading to dependence and in turn, increased consumption of them.
Multi-component psychological interventions have proven broadly to be effective for smoking cessation. Nevertheless, relapse rates after treatment remain high. Between 40% and 70% of patients who complete treatment return to smoke. Therefore, it is necessary to incorporate more effective strategies for relapse prevention in such programs. Individuals with substance-use disorders have increased craving after exposure to drug-related cues, a phenomenon known as cue-reactivity. Cue-induced craving is considered responsible for relapse after smoking cessation. Cue Exposure Treatment (CET) consists of controlled and repeated exposure to stimuli associated with substance use to extinguish craving responses.
Conventionally, cue-reactivity studies have used a variety of modes of cue presentations including imagery scripts, photographs, videos, or drug paraphernalia. The limited long-term effectiveness of behavioral treatments and pharmacotherapy coupled with the durability of cue-induced craving highlights the need for novel treatment approaches to manage and accelerate the relief of cue-induced cigarette craving to prevent smoking relapse. It has been well documented that in vivo (holding a lit cigarette, ashtray, lighter, watching someone smoke) and in vitro (pictures, brief videos, imagery scripts describing smoking urges) smoking cue exposure sensitizes smokers to cigarettes. The results of a meta-analysis found that these methods elicit robust cue-reactivity effects compared with neutral cues.
Accordingly, researchers have developed controlled laboratory methods for studying smokers' reactions to cues. In the cue-reactivity paradigm, smokers are exposed in the laboratory to stimulus cues thought to be associated with smoking, such as the sight and/or smell of cigarettes themselves, and such cigarette cues reliably elicit craving. Individual differences in reactivity have been associated with dependence and greater vulnerability to relapse, but only inconsistently. The vast majority of cue-reactivity research has been conducted using “proximal” cues – that is, cues associated with the act of smoking itself, usually a cigarette. This would be expected to be the cue with the strongest associations since it is always present prior to and during smoking and has unique sensory characteristics.
A recent mode of cue presentation that has received increasing attention in the literature is the use of virtual reality (VR). VR uses computer-based technology to generate three-dimensional environment that allows people to move through their surroundings and interact with the created environment. VR has been utilized for the assessment and treatment of several psychological conditions including social anxiety disorder, posttraumatic stress disorder, specific phobias, schizophrenia, eating disorders, and addictive behaviors. In substance-use disorders, VR has been used mainly to assess craving and reactivity to drug-related cues including nicotine, alcohol, cocaine, methamphetamine, opioids, and cannabis.
VR technology has shown its efficacy as an exposure tool in several psychopathological disorders. VR exposure provides several advantages over conventional methods since it allows participants to experience vivid real-life re-creations, VR permits a strict control over variables while maintaining a high ecological validity. Several studies have shown that VR could be a good alternative to traditional exposure methods to generate craving. Nevertheless, as most of them use decontextualized cues, its generalization to everyday life situations becomes difficult. A smoker using the system can experience a VR of smoking by puffing on a cigarette-shaped article and experiencing the taste or aroma from the article while simultaneously viewing a generated image of a burning cigarette and exhaled and sidestream smoke. Various studies have shown that virtual environments embedded with smoking-related cues are able to produce increased in craving compared with virtual environments containing neutral cues.
The aim of our study was to determine the suitability of VR for simulating smoking among current cigarette smokers in Chennai city.
| Materials And Methods|| |
A cross-sectional study was performed among truck drivers in Madhavaram, Chennai, from February to April 2019.
The study was conducted following approval by the Ethical Committee, Ragas Dental College and Hospital, Chennai. Further, permission was also obtained from the proprietors of the concerned truck agencies. The general guidelines to ensure the rights of participants were followed. Prior to the investigation, informed consent was obtained from individual participants and the study information was reaffirmed orally.
| Sample size|| |
The sample size was calculated based on data obtained from the study conducted by Sukumaran et al. among bus drivers at Koyambedu, Chennai. The prevalence of smoking (19%) among private bus drivers and the prevalence of smoking in India according to GATS2 survey (12.8%) was considered for the sample size calculation. G power (version 3.1, Copyright © 2021. University of North Carolina Greensboro, 1400 Spring Garden Street, Greensboro, NC 27403) software was used for sample size calculation. Considering a prevalence of 19% and 12.8% using a power of 80%, the sample size was calculated as 40. The sample was diverse in nature pertaining to ethnicity, socio-economic status, and education.
A purposive sampling was used to include forty current mild smokers from a truck drivers association in Chennai. The sample was diverse in nature pertaining to ethnicity, socio-economic status, and education.
Inclusion and exclusion criteria
The participants who were above the age of 18 years and present on the day of study and willing to participate in the study and current mild smokers as per Modified Fagerstrom Test for Nicotine Dependence score (0–2) for smoking tobacco were included in the study.
Participants involved in any smoking cessation treatment, suffering from substance dependence other than nicotine, severe hearing impairment, history of serious medical conditions, history of seizure, fear of closed spaces, or visual problems that may impair ability to view VR materials were excluded.
| Data collection|| |
Data were collected through a face-to-face interview. Demographic characteristics, which included questions concerning age, gender, education, and marital status was enquired initially. Suitability of VR to simulate smoking was assessed using suitability evaluation questionnaire (SEQ) which included 14 questions, 13 of them with a response graded on a 5-point Likert Scale, and a last open question.
Suitability evaluation questionnaire questionnaire
The first seven questions in SEQ questionnaire measure enjoyment, sense of being in the system, feeling of success and control, realism, easy-to-understand instructions, and general discomfort.
After, four new questions (Q8-Q11) are included to detect issues frequently associated with virtual rehabilitation systems: dizziness or nausea symptoms, eye discomfort, disorientation or confusion symptoms, and sense of progress in rehabilitation. These first eleven questions are graded from “Not at all” to “Very much.”
Difficulty with the system
The last two 5-point Likert scale questions are focused on difficulty: Q12 evaluates the perceived difficulty of the task (as the last question of the SFQ) and Q13 evaluate the observed difficulty related with the physical interface used in the system. Q12 and Q13 are graded from “Very easy” to “Very difficult.” The global score of SEQ ranges from 13 (poor suitability) to 65 (excellent suitability). In their calculation, it is necessary to consider that items Q7, Q8, Q9, Q10, Q12, and Q13 are negative items (that is, a response of 1 has a value of 5, a response of 2 has a value of 4,…).
Finally, an open question (Q14) asks patients if they felt uncomfortable, requesting the reasons why. The questionnaire has a convenient number of questions (14), enough to measure the suitability of the system but not too many for the patients. Questions are direct and clear, and SEQ also takes into account issues concerning VR system. The questionnaire which was both in English and local language (Tamil) was given to the study participants.
The data were collected during an oral health screening program for truck drivers working in private agencies in Chennai. Participants were exposed to virtual video simulating smoking using a VR camera that reproduced typical situations how people smoke. The system used in this study imitates the physical and/or sensorial pleasures of smoking by providing smoking sensations such as the feel and visual experiences of smoking a tobacco product like a cigarette but without actual smoking or burning of tobacco.
Virtual reality system
In order to accurately simulate human action within a virtual environment, VR systems aim to facilitate input and output of information representing human senses. In many situations, among all the human senses, sight (or visual input) is useful as an evaluative tool. Accordingly, a display system for visualization is preferably part of a VR system. Visual simulation can be provided to immerse a smoker into a virtual smoking experience. Visualization in VR system was accomplished by means of a head-mounted display worn on a smoker's head with a viewing display mounted in front of the smoker's eyes.
Virtual reality simulation content
The VR environment simulating video designed to mimic a real-life smoking setting to provide a realistic and immersive experience to patients was obtained. In this simulating video, a visualization technique based on volume rendering and smoke dynamics data have been especially designed to create a realistic and accurate smoking environment for the purposes of effective virtual environment, which allows the participants to experience a realistic scenario.
A burning cigarette would be seen facing the participant. The movement of the cigarette in the video would be in such a way that it increases the realism of the VR smoking environment. A smoker using the technology can experience a VR of smoking by puffing on any article which has the dimensions and appearance of a traditional cigarette, pipe, etc., while simultaneously viewing a generated video of a burning cigarette. The participant moves his/her hand up and down to simulate cigarette puffing. Additionally, the room environment was simulated to give the experience of smoking in a setting of the smoker's choice such as at a home setting, a lounge of a cigar store, or the like. Side-stream can also be provided for visualization similar to a side-stream smoke pattern from a burning cigarette. The pattern and characteristics of the side-stream smoke would be different from exhaled smoke. Each participant completed one VR session of 5 min each. Sense of satisfaction experienced by participants in the virtual environments was assessed at the end of the experiment using SEQ which was administered immediately after the session with VR.
Data collection and management were conducted using the Microsoft Office Excel package in association with the SPSS 20.0 software package (SPSS Inc., IBM Corp., located in Armonk (N.Y., USA) in 2009) for the statistical analysis. Qualitative data were presented as frequency and percentages and quantitative data as mean and standard deviation (SD).
| Result|| |
Forty current mild smokers with a mean age of 47.23 ± 12.43 participated in the study. Characteristics of the sample are presented in [Table 1]. Relating to the suitability of VR system, individual scores ranged from 43 to 50 with a mean score of 46.93 ± 2.61 where a score of 65 represents excellent suitability.
Thus, the suitability of VR for simulating smoking among current mild cigarette smokers according to the SEQ scale showed intermediate suitability [Table 2].
|Table 2: Suitability of virtual reality for simulating smoking according to the suitability evaluation questionnaire scale|
Click here to view
Relating to each domain, patients were moderately able to control the system (Q1 to Q7, mean ± SD = 22.04 ± 4.2), had less issues associated (Q8 to Q11, mean ± SD = 16.83 ± 1.67) and did not have any difficulty with the system (Q12 and Q13, mean ± SD = 7.92 ± 2.3).
Relating particular items, patient's moderately accepted the system (Q1, mean ± SD = 2.76 ± 0.6) and patients thought that VR will be helpful for their smoking simulation and thus cessation (Q11, mean ± SD = 2.38 ± 1.00). Only one of the 40 patients felt uncomfortable due to neck pain.
| Discussion|| |
Smokers have to face different situations every day that either cannot or should not be avoided. The majority of smokers affirm that the biggest difficulty in the process of quitting smoking is linked to the inability to resist, even if they are aware of the negative effects of this behavior. That is why craving is an important element of quitting strategies. Through cue exposure therapy, smokers are exposed repeatedly to smoking-related cues to reduce the reactivity. The argument for using exposure to stimuli to treat nicotine dependence is based on the classical conditioning learning model. Thus, in the nicotine addiction, the nicotine is an unconditional stimulus and the effects of nicotine are the unconditioned responses. The conditions or contexts in which a person smokes very often become conditioned stimuli that determine the appearance of conditioned responses, and this leads to craving and nicotine consumption. Smoking cues decrease the latency to smoke, especially under lean reinforcement conditions. To be a successful relapse prevention strategy, repetitive imagery may need to be practiced prior to smoking cessation.
Thompson-Lake et al. concluded that exposure to virtual environments with specific stimuli increases the level of craving felt by smokers. These results can confirm that a cue-exposure process using VR can be a useful strategy in smoking cessation. Smokers who were better able to focus during the imagery waited longer before smoking a cigarette. Greater proficiency in the mental simulation will likely require fewer cognitive resources when smoking abstinence-induced cognitive deficits are common. Performing the mental imagery that would accompany smoking should evoke the same response as actually smoking– habituation to cigarettes. Inspection of the average changes in cue-induced craving after repetitive imagery showed that craving was declining, but the difference between limited and repetitive imagery was smaller than anticipated. It is possible that either type of imagery provided an engaging distraction that permitted a reduction in craving across the minutes that followed the cue. Smoking cessation approaches that strive to heighten awareness and acceptance of craving while “riding it out” until it passes, have shown preliminary support for shorter-term smoking cessation.,,
The cue-specific craving effects associated with VR manipulations were large and comparable in magnitude to the effect sizes found with more conventional modes of cue presentation as reported in the meta-analysis by Carter and Tiffany. Earlier studies have reported that more attention, visual balance, and coordinating movement were observed during the exposure to smoking-related cues using VR. Even though both VR and traditional methods of cue exposure can elicit strong cue-induced craving, VR provides realistic environments for cue exposure that would be impossible to create with conventional cue presentation procedures.
Previous studies have examined smokers' responses to smoking-related and neutral cues finding that smoking-related cues, such as viewing or holding a cigarette, imagining a scenario involving smoking or being at smokers' real situations, elicits greater reactivity. Likewise, several studies have reported the success of virtual environments for inducing smoking craving. Nevertheless, earlier studies only use virtual paraphernalia or avatars smoking in bars or parties as cues. In contrast, our study provides evidence about the capability of virtual environments simulating a wide range of real-life situations to elicitate craving in smokers. Our study results reported intermediate suitability of VR for simulating smoking among current mild cigarette smokers according to the SEQ scale which was slightly in contrast with the findings of Amy C. Traylor et al. who stated that VR effectively delivers smoking cues that gain the attention of young adult smokers and increases their thoughts of smoking when confronted with these complex, contextually appropriate cues. In support of this, a study by Carter and Tiffany, concluded that using VR-based exposure in treatment can allow clinicians to adapt treatment to individual needs and bring up discussion of potential skill deficits that remain despite abstinence. VR-based cue exposure and assessment can offer a standardized clinical tool appropriate for both clinical and research settings.
Regarding the limitations of this study, it would have been useful to have participants with different levels of nicotine addiction to see if the perceived level of suitability would be different. The primary measures were self-reported suitability. As with measures based on self-report, there is the possibility of bias in data collection. The generalizability of the current findings is limited since the study was conducted in a southern metropolitan city, and the sample may not be characteristic of smokers in other areas.
| Conclusions|| |
Overall, VR-based cue exposure can advance current nicotine-dependence treatment and provide a validated platform for treatment and research applications. The results of our study suggest that VR environments that simulate real situations are suitable to elicit craving and thus assist in smoking cessation. VR technology could be useful in the improvement of Cue Exposure Therapy (CET) for substance use disorders and more specifically for smoking cessation programs. Moreover, having a wide number of virtual situations would enhance the probability of generalization of extinction in real life.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The study was conducted following approval by the Ethical Committee, Ragas Dental College and Hospital, Chennai.
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[Table 1], [Table 2]