Crushing virtual cigarettes helps
reducing tobacco addiction.
Final results from a preliminary control trial
Girard1, B., Turcotte1, V., & Bouchard2, S.
1GRAP,
Occupational psychology clinic
2Université du Québec en Outaouais
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PILOT STUDY 2007
OBSERVATIONS:
1. Some clinical indications of modifying
craving and smoking behaviours.
2. An action-cue exposure (ACET) strategy
could be considered in the treatment of
substance addiction.
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COMPARATIVE STUDY 2008
• Objective of the current study:
– Test the advantages of adding to a psychosocial
smoking cessation treatment program for adults four
(4) sessions of immersion in virtual reality where the
patient uses a virtual arm to crush cigarettes.
• Hypothesis:
– Compared to the placebo condition, crushing virtual
cigarettes will lead to:
• Better reduction in tobacco addiction
• Better abstinence
• Better retention in the program
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DESIGN
• 91 subjects randomly assigned
• Combined therapy (no medication):
 psychosocial support + crushing virtual cigarettes
 psychosocial support + grasping virtual balls
• No target quit date
• Study has been approved by the Research
Ethics Board of UQO
• “Internal funding”
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PRESELECTION (telephone)
• Recruitment through local medias
• Inclusion criteria :
Age between 18 – 65
Daily smoking 10 cigarettes and more (last year)
Fewer than 3 months abstinence (last year)
Desire to stop smoking
• Exclusion criteria :
Any serious or unstable disease (6 months)
Treatment for major mental illness (last year)
Use of medication to stop smoking (6 months)
Regular use of CNS medication
Treatment with “cybertherapy” (last year)
History of severe substance abuse (last year)
Pregnancy
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SELECTION (clinic visit)
• Physical data :
• Smoking history :
•
•
•
•
•
vital signs
body mass index
age
duration
number of attempts
abstinence periods
mean daily use
Exhaled CO test
Questionnaires
VR adaptation session (10 min.) and tests
Informed consent document
Randomization
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INTERVENTION (1)
Psychosocial support
• Brief individual counselling (10-15 min) by a nurse :
assist in problem solving, give information on withdrawal,
analyse smoker’s journal.
• Smoking cessation self-help booklet :
Guide to
becoming a non smoker (Health Canada 2003).
• Exhaled CO test, vital signs and body mass index.
• Complete questionnaires.
• Frequency of visits : - weekly for 1 to 4th week
- biweekly for 6th to 12th week
• Medical counselling (if necessary)
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INTERVENTION (2)
Immersion in virtual reality (all participants)
• Four weekly sessions : week 1 to 4th
• Time : 30 min.
• VR scenario, while exploring a castle either:
– Grasping up to 50 virtual balls (placebo ctrl)
– Crushing up to 50 virtual cigarettes
• Complete questionnaires
• Wait time after the immersion before leaving the
office : 10-15 min.
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EQUIPMENT
• Pentium IV with nVidia
7300GS stereo video card
• eMagin z800 HMD
• Logitech wireless gamepad
• XSI from Softimage was used for
the virtual arm and environment’s
creation
• 3D work was integrated into
a well-know game engine
called Unreal 2™ from
Unreal Tournament 2004™.
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Video
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Measures : (each visit at the clinic)
Outcome
• Addiction:
– Fagerström test for nicotine dependence (Heatherton, 1991)
• Smoking status:
– Daily self report journal
– Exhaled CO test (cut-off at 6 ppm).
• Drop out rate:
– Stopping the program, no matter the reason…
Process / side effects
• Presence Questionnaire (PQ; Witmer & Singer, 1998).
• Simulator Sickness Questionnaire (SSQ; Kennedy et al., 1993).
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RESULTS
Descriptive characteristics:
• n = 45 in the control condition (Balls)
• n = 46 in the experimental condition (Cigarettes)
• Average age: 44 years (SD = 11 years)
• Had been smoking for an 27 years (SD = 12 years).
• Gender: 57% female.
• Work status: 68% employed.
• Smoking frequency: 45 % smoked more than 21
cigarettes a day.
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Results (intent-to-treat)
Fagerström test
10
9
8
7
6
5
4
3
2
1
0
Week 1 (pre)
Week 4 (post VR)
Balls
Week12 (post)
Cigarettes
ANOVA : Time [F(2,178) = 33.07, p < .001)]
Condition [(F(1,89) = 4.69, p < .025]
Time/Condition interaction [F(2,178) = 3.75, p < .05]
Interaction contrast :
p < .01 at W4 / W12
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Results (intent-to-treat)
Abstinence (confirmed by CO test)
16
14
12
10
8
6
4
2
0
Week 1 (pre)
Week 4 (post VR)
Balls
On a phone call 6-month post-Rx:
Cigarettes: 39% abstinent
Balls: 20 % abstinent
Week 12 (post)
Cigarettes
χ2 (1) = 1.84, ns
χ2 (1) = 4.79, p < .05
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Retention rate in the program
Number of patients in the program
A significantly different retention profile
[Gehan's Wilcoxon test (1) = 6.96, p < .01].
50
45
40
35
30
Balls
25
Cigarettes
20
15
10
5
0
1
2
3
4
6
8
10
12
Weeks
Significantly more controls had dropped-out of treatment:
at week 4 [22% vs 49%, χ2 (1) = 7.35, p < .001]
at week 12 [50% vs 71%, χ2 (1) = 4.24, p < .05].
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Process and side effects
• A multiple regression with PQ predicting change on the
Fagerström was significant [F(2,90) = 39.78, p < .001]
and showed that presence contributes significantly to
changes in scores measuring tobacco addiction (sr2 = .18, p < .025).
• Cybersickness : [F (1,57) = 4.10, p < .05]
Week 1
Week 2
Week 3
Week 4
Grasping virtual
balls condition
Mean (SD)
Crushing virtual
cigarettes condition
Mean (SD)
39.39 (48.72)
41.62 (42.45)
41.77 (44.01)
28.67 (41.47)
81.93 (70.11)
58.91 (55.57)
51.91 (45.53)
51.24 (62.55)
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Conclusion
• Crushing virtual cigarettes had a significant effect on:
– Fagerström (addiction)
– Abstinence (confirmed by CO tests)
– Drop-out (retention)
• Why ?
– Staying longer in the treatment…
• Ok, but again, why?
– Self-efficacy to crush burning cigarettes ?
– Motivation to crush, to quit, enjoy crushing, stages of change ?
– Practicing an automatic response ?
• Action cue exposure ?
– New association with positive mood and smoking cessation ?
• Seeing cigarettes is no longer associated with frustration…
• More research is clearly needed …
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