Comparison of the Effectiveness of Virtual Cue
Exposure Therapy and Cognitive Behavioral
Therapy for Nicotine Dependence
Chan-Bin Park, MA,
Jung-Seok Choi, MD, PhD,
Su Mi Park, MA,
Jun-Young Lee, MD, PhD,
Hee Yeon Jung, MD, PhD,
Jin-Mi Seol, MA,
Jae Yeon Hwang, MD,
Ah Reum Gwak, BA,
and Jun Soo Kwon, MD, PhD
Previous studies have reported promising results regarding the effect of repeated virtual cue exposure therapy
on nicotine dependence. This study aimed to compare the effectiveness of virtual cue exposure therapy (CET)
and cognitive behavioral therapy (CBT) for nicotine dependence. Thirty subjects with nicotine dependence
participated in 4 weeks of treatment with either virtual CET (n=15) or CBT (n=15). All patients were male, and
none received nicotine replacement treatment during the study period. The main setting of the CET used in this
study was a virtual bar. The primary foci of the CBT offered were (a) smoking cessation education, (b) with-
drawal symptoms, (c) coping with high-risk situations, (d) cognitive reconstruction, and (e) stress management.
Daily smoking count, level of expiratory carbon monoxide (CO), level of nicotine dependence, withdrawal
symptoms, and subjective craving were examined on three occasions: week 0 (baseline), week 4 (end of treat-
ment), and week 12 (follow-up assessment). After treatment, the daily smoking count, the expiratory CO, and
nicotine dependence levels had signiﬁcantly decreased. These effects continued during the entire study period.
Similar changes were observed in both virtual CET and CBT groups. We found no interaction between type of
therapy and time of measurement. Although the current ﬁndings are preliminary, the present study provided
evidence that virtual CET is effective for the treatment of nicotine dependence at a level comparable to CBT.
Nicotine dependence, the most prevalent and deadly
substance use disorder, involves compulsive use in the
face of adverse consequences and repeated cycles of absti-
nence and relapse.
Of the numerous factors associated with
treatment outcome, craving is considered a primary trigger
Additionally, environmental stimuli (context-
speciﬁc stimuli or cues) that are repeatedly associated with
cigarettes are known to promote compulsive smoking.
Craving and cue reactivity have been conceptualized as
classically conditioned responses.
Cue exposure therapy
(CET) is based on the assumption that environmental stimuli
that are repeatedly associated with a drug can come to elicit
conditioned responses that lead to craving and relapse.
for nicotine dependence is based on the notion that prolonged
and repeated nonreinforced presentation of smoking cues
(conditioned stimuli) will result in a gradual diminution of
craving (conditioned response) through Pavlovian extinction
CET, however, is limited in terms of the environmental
cues that can be simulated and the degree to which immer-
sion experiences can be presented. Furthermore, it has shown
decreased efﬁcacy over time.
Thus, a virtual reality (VR)
variation on cue exposure treatment (VR-CET) has been de-
veloped as an alternative to CET.
VR is an evolving tech-
nology that produces interactive environments with
stereoscopic, three-dimensional (3D) visual displays, audi-
tory input, and immersive interaction from a ﬁrst-person
A previous study used virtual paraphernalia or
avatars smoking at parties or in bars, selecting the situation to
be recreated as an ad hoc virtual environment.
studies have shown the effectiveness of VR extinction for
reducing cue-elicited craving, and have demonstrated that
this approach is more effective in eliciting conditioned re-
sponses than are conventional methods such as traditional
slides or videos.
According to clinical practice guideline,
there are two
types of counseling and behavioral therapies resulting in
higher success rates: (a) providing smokers with practical
Department of Psychiatry, SMG-SNU Boramae Medical Center, Seoul, South Korea.
Department of Psychiatry, Seoul National University College of Medicine, Seoul, South Korea.
CYBERPSYCHOLOGY,BEHAVIOR,AND SOCIAL NETWORKING
Volume 17, Number 4, 2014
ªMary Ann Liebert, Inc.
counseling such as problem solving/skills training/stress
management, and (b) providing support and encouragement
as part of treatment. Cognitive behavioral therapy (CBT) is
suitable to meet these aims, and favorable outcomes and
positive effects have been reported.
However, no study has compared effectiveness of CBT
with that of VR-CET, despite empirical evidence that has been
In this preliminary study, we aimed to
compare the effectiveness of short-term VR-CET with that of
CBT for subjects with nicotine dependence. We hypothesized
that the effectiveness of VR-CET would be comparable to that
of conventional CBT for nicotine dependence.
Materials and Methods
Thirty participants who smoked cigarettes daily and
showed at least a moderate nicotine dependence level based
on the Fagerstro
¨m Test were enrolled. All participants were
male and treatment seeking. Subjects were recruited via the
smoking cessation clinic at the SMG-SNU Boramae Medical
Center, and none received nicotine-replacement treatment or
any other medications during the study period. Exclusion
criteria included the following: known history of alcohol or
drug abuse/dependence other than that involving nicotine;
neurological disease or brain injury; evidence of medical ill-
ness that could manifest in psychiatric symptoms; and psy-
chiatric disorders conﬁrmed by the Structured Clinical
Interview for DSM-IV.
This study was conducted in accor-
dance with the Declaration of Helsinki. The Institutional Re-
view Boards of the SMG-SNU Boramae Medical Center
approved the study protocol, and all subjects provided
written informed consent prior to participation.
Before the experimental intervention, data on demographic
characteristics, medical history, and smoking behavior (daily
smoking count and typical locations for smoking) were col-
lected from participants. All subjects with nicotine depen-
dence participated in four weekly treatment sessions under
one of two conditions: VR-CET (n=15) or CBT (n=15). Both
treatments were conducted once a week for 4 weeks. After the
end of each session, the researchers administered the Fager-
¨m Test for Nicotine Dependence (FTND), Questionnaire
of Smoking Urges (QSU), and expiratory carbon monoxide
(CO) level to each subject. Participants who completed the
four-session treatment visited the clinic on a monthly basis as
a follow-up interview and engaged in simple counseling.
Questionnaires and rating scales were completed on three
occasions: week 0 (baseline), week 4 (end of treatment), and
week 12 (follow-up assessment). Subjects in the two groups
were demographically matched (Table 1).
Expiratory CO concentration. The expiratory CO con-
centration is the CO level remaining in the alveoli after
smoking. We used a Micro CO Meter (Cardinal Health,
Chatham, UK), which is a hand held battery operated device
used to measure the concentration of CO on the breath and
calculates the percentage of carboxyhaemoglobin (%COHb)
in the blood. Daily smoking counts and expiratory CO levels
were monitored to determine whether participants smoked
during the study. Smoking cessation success or failure was
determined based on information provided by the subjects at
weeks 4 and 12, and veriﬁed by expiratory CO levels p6.
Nicotine dependence level. The FTND was used to mea-
sure the participants’ dependence on nicotine.
which consists of six questions, is strongly correlated with
pulse rate, body temperature, and cotinine levels, the primary
metabolite of nicotine. Scores range from 0 to 10; scores of 3–6
are considered to reﬂect a moderate level of nicotine depen-
dence, and those higher than 7 are considered to reﬂect a severe
level. Participants with at least a moderate dependence (scores
of 4 and higher) were included in this study.
Withdrawal symptoms. The Minnesota Nicotine With-
drawal Scale (MNWS) is a 15-item self-report questionnaire
used to assess withdrawal symptoms. It has been validated in
multiple studies and demonstrated sensitivity to abstinence
symptom and good reliability and validity.
Subjective craving. A 32-item self-report version of the
QSU was administrated to assess subjective craving.
factor solution best described the item structure of the QSU.
The ﬁrst factor consisted of a strong desire and intention to
smoke and a perception that smoking is rewarding for active
smokers. The second consisted of an anticipation of relief from
negative affect associated with an urgent desire to smoke.
Condition 1: VR-CET. Participants allocated to the VR-
CET group experienced four serial VR cue exposure
Table 1. Demographic and Clinical Characteristics in Study Subjects
VR-CET (n =15) CBT (n =15)
Variables Mean (SD) Mean (SD) t p
Age (years) 30.73 (6.60) 33.07 (5.47) -1.05 0.30
Daily smoking counts 20.67 (4.17) 20.33 (4.41) 0.21 0.83
Expiratory CO 13.07 (3.61) 13.73 (3.63) -0.50 0.62
¨m Test 4.87 (1.06) 5.80 (1.15) -2.31* 0.03*
Minnesota nicotine withdrawal 9.93 (3.53) 7.20 (4.06) 1.96 0.06
Smoking urges 108.47 (28.02) 112.13 (49.09) -0.25 0.80
*p<0.05. SD, standard deviation; VR-CET, virtual reality-cue exposure therapy; CBT, cognitive behavioral therapy; CO, carbon monoxide.
VIRTUAL CET VS. CBT IN NICOTINE DEPENDENCE 263
environments in a 3D surround screen projection room
equipped with real time psychophysiological response
monitoring. The primary focus of the VR used in this study
was a ‘‘virtual bar’’ because bars are the most frequent
smoking environment according to the results of a previous
Only those participants who reported that their
urge to smoke was most powerful in situations involving
alcohol were assigned to this condition. The treatment pro-
cedure was as follows. Researchers conﬁgured the four dif-
ferent VR environments (a, neutral cue; b, smoking-related
objects; c, social situation related with smoking; d, neutral
cue). Participants were exposed to this series of environments
for approximately 25 minutes per visit. After each environ-
ment ended, participants were asked to check the severity of
nicotine craving using a mouse button. The detailed infor-
mation about VR-CET, including a screenshot of the virtual
bar, was described in the previous report.
Condition 2: CBT. In a systemized smoking cessation
clinic, psychosocial treatments commonly utilized are based
on the CBT approach. In this study, four sessions of the CBT
protocol were used, which researchers reconstructed within
the framework of adequate treatment based on the previous
The primary foci of the CBT offered were (a)
smoking cessation education, (b) withdrawal symptoms, (c)
coping with high-risk situations, (d) cognitive reconstruction,
and (e) stress management. Participants received individual
CBT from a psychiatrist at a smoking cessation clinic in the
SMG-SNU Boramae Medical Center, and none received nico-
tine replacement treatment or any other medication during
the study period.
All statistical analyses were conducted with SPSS v17.0
(SPSS Inc., Chicago, IL). A repeated measures analysis of
variance (ANOVA) was used to analyze changes in the target
variables as a function of the treatment condition. Bonferroni
post hoc correction was used to compare mean differences
between measurements taken at different times. Chi-square
tests were used to analyze differences in the success and
failure rates under both conditions. Statistical signiﬁcance
was set at 0.05 (two-tailed).
Repeated measures ANOVAs revealed signiﬁcant reduc-
tions in daily smoking count, expiratory CO levels, and level
of nicotine dependence as the study proceeded. As shown in
Table 2, we found main effects for time of measurement
(week 0, 4, or 12) on daily smoking count, expiratory CO
levels, and level of nicotine dependence, and post hoc anal-
ysis conﬁrmed that every score recorded at week 4 (end of
treatment) was signiﬁcantly lower than its baseline counter-
part ( p=0.00). No signiﬁcant interaction between measure-
ment time and treatment condition was observed (Table 2).
Moreover, subjective cravings decreased as the study pro-
ceeded, although these differences were not statistically sig-
niﬁcant. With regard to nicotine withdrawal symptoms, we
found a main effect of MNWS scores but no signiﬁcant in-
teraction between treatment group and time of measurement.
Post hoc pairwise comparisons conﬁrmed the signiﬁcant in-
crease in withdrawal symptoms at the end of 4 weeks of
treatment ( p=0.00), but these symptoms decreased to below
baseline levels after 12 weeks ( p=0.05). After 4 weeks, 10 out
of 15 participants in the VR-CET group succeeded in main-
taining their nonsmoking status; as did 11 of the participants
in CBT group. Until the research was completed (week 12),
seven of the participants in the VR-CET group were suc-
cessful in quitting, and eight of the participants in the CBT
group maintained their abstinence. Chi-square analyses re-
vealed no signiﬁcant differences between the groups in the
distribution of participants who had successfully stopped
smoking (week 4: v
=0.16, p=0.69; week 12: v
To our knowledge, the present study is the ﬁrst to com-
pare the effectiveness of VR-CET and CBT for treating nic-
otine dependence. In this study, both therapies were offered
in a short-term format, and weekly changes under the two
conditions were compared. We found that signiﬁcant de-
creases in daily smoking counts, levels of nicotine depen-
dence, and expiratory CO levels of both groups were
observed after 4 weeks, and these changes continued until
the study terminated (week 12).Second, signiﬁcant in-
creases in nicotine withdrawal symptoms of both groups
were reported after 4 weeks of therapy, but these values
Table 2. Analysis of the Smoking Related
Variables at Baseline, Week 4, and Week 12
in the VR-CET and CBT Groups
FpPost hoc (Bonferonni)
Daily smoking counts
110.17 0.00** Week 0 >week 4,
0.16 0.70 Week 4 <week 12
Time ·condition 0.09 0.91
Time 54.82 0.00** Week 0 >week 4,
Condition 0.06 0.81
Time ·Condition 0.58 0.57
Time 84.39 0.00** Week 0 >week 4,
Condition 0.17 0.68 Week 4 <week 12
Time ·Condition 1.68 0.20
Minnesota nicotine withdrawal
Time 29.13 0.00** Week 4 >week 0,
Condition 0.45 0.51 Week 0 >week 12
Time ·Condition 1.09 0.34
Time 2.55 0.09
Condition 0.01 0.93 —
Time ·Condition 0.10 0.91
Time: week 0 (baseline), week 4 (end of treatment), week 12
Condition: VR-CET, CBT.
In the post hoc column, signiﬁcant pairs only listed.
264 PARK ET AL.
returned to baseline levels at week 12. Finally, two-thirds of
the participants succeeded in maintaining their nonsmoking
status at the end of treatment (week 4), and almost half the
participants maintained their abstinence until the research
was completed. Similar trends were observed among those
in both groups.
Despite the existence of empirically validated psychologi-
cal and pharmacological treatments for nicotine depen-
high relapse rates underscore the need to develop
more effective strategies for maintaining abstinence. Our re-
sults show that both VR-CET and CBT are effective treatment
modalities for nicotine dependence. Even more importantly,
VR-CET was associated with a signiﬁcant treatment effect
that was similar to the effect of CBT.
Of the treatments used for smoking cessation, CBT is
typically selected in practice. CBT focuses on cognitive re-
structuring, education, self-monitoring, and practical coping
strategies aimed at successful smoking cessation. Due to the
nature of the approach, CBT devotes a large amount of time
to education during the early stage of treatment. However,
this sometimes reduces the immediacy of the treatment and
poses barriers to early engagement. Ensuring the expertise of
practitioners remains challenge and time–cost considerations
are also present.
In this context, VR-CET has emerged as a new treatment
for smoking cessation. This approach involves repeated
exposure to nicotine-related cues with the goal of reducing
cue reactivity via extinction. Actual cue exposure is the core
treatment element of CET, and no techniques of active ex-
posure took place in CBT, thus establishing a clear differ-
ence between the two approaches.
It is easier to validate
the contents in VR-CET, and the administration procedure
is simple as well. Although previous studies have noted the
limitations of this approach related to the restricted variety
of stimuli presented and individual differences in cue re-
virtual reality makes it possible to recreate the
complexity of a smoking environment. This may increase
realism and enhance participants’ motivation by using sci-
entiﬁcally and ecologically validated contexts and cues.
This is reﬂected in the previous research that patients fa-
vored CET with regard to usefulness and practicability of
These factors may render treatment
On the other hand, no signiﬁcant changes in subjective
cravings were found. This result may be explained by the
following considerations. First, the intervention performed
in this study was short term. Duration of intervention may
not be sufﬁcient to achieve extinction through repeated ex-
posures in the CET model or for new coping skills to become
habitual in the CBT model. Second, a selection bias may
have affected the results for the VR-CET condition. As
mentioned earlier, those who experienced the strongest urge
to smoke in drinking situations were assigned to the VR-
CET group, and the only smoking cue used for this group
FIG. 1. Changes in smoking-related variables at baseline, week 4, and week 12 in the VR-CET and CBT groups. VR-CET,
virtual reality-cue exposure therapy; CBT, cognitive behavioral therapy; CO, carbon monoxide; *p<0.05 signiﬁcant mean
difference compared to baseline.
VIRTUAL CET VS. CBT IN NICOTINE DEPENDENCE 265
was alcohol related. It would be expected that the urge to
smoke would decrease in a drinking situation. However,
generalization to other situations would be surprising. Fu-
ture research should identify and test a variety of smoking
cues and situations.
One important concern in the study is the absence of a
control group of smokers not involved in VR or CBT treat-
ment, which may lead to the question of whether this change
was due to time course or the real effect of the treatment itself.
However, we tried to exclude the effect of time course indi-
rectly. Previous research revealed that speciﬁc types of
counseling and behavioral treatment yielded a statistically
signiﬁcant increase in abstinence rate relative to no contact
(untreated control condition).
Some limitations of the present study should be pointed
out, such as the small sample size and the inclusion of only
male participants. A possible bias might be the motivation
of the subjects involved in the study, which could have
been higher than subjects saying that they wanted to stop
without a strong motivation. These factors limit the gen-
eralizability of the results. However, we included only
drug-naive participants. It is important to recruit a homo-
geneous sample to control for confounding factors such as
medication and sex.
Although the underlying therapeutic mechanisms differed,
the two treatments examined here were both effective for
smoking cessation. This result may suggest the potential of
constituting a new treatment modality. Future research is
needed to evaluate the possible combined effect of both
treatments and to explore the possibility of combining VR-
CET incorporating a variety of smoking-related stimuli with
components of CBT.
This work was supported by a grant from the SNUH Re-
search Fund (30-2011-0210).
Author Disclosure Statement
No competing ﬁnancial interests exist.
1. World Health Organization. (2009) WHO report on the
global tobacco epidemic, 2009: implementing smoke-free
environments. Geneva, Switzerland; WHO.
2. Carter BL, Tiffany ST. Meta-analysis of cue-reactivity in
addiction research. Addiction 1999; 94:327–340.
3. Shalev U, Grimm JW, Shaham Y. Neurobiology of relapse to
heroin and cocaine seeking: a review. Pharmacological Re-
views 2002; 54:1–42.
4. See RE. Neural substrates of conditioned-cued relapse to
drug-seeking behavior. Pharmacology Biochemistry & Be-
havior 2002; 71:517–529.
5. Conklin CA, Tiffany ST. Applying extinction research and
theory to cue-exposure addiction treatments. Addiction
6. Torregrossa MM, Taylor JR. Learning to forget: manipulat-
ing extinction and reconsolidation processes to treat addic-
tion. Psychopharmacology 2013;226:659–672.
7. Kantak K, Nic Dhonnchadha B. Pharmacological enhance-
ment of drug cue extinction learning: translational chal-
lenges. Annals of the New York Academy of Sciences 2011;
8. Eichenberg C. (2012) Virtual reality in psychological, medical
and pedagogical applications. New York: InTech.
9. Martin T, LaRowe S, Malcolm R. Progress in cue ex-
posure therapy for the treatment of addictive disorders:
a review update. Open Addiction Journal 2010; 3:92–
10. Coiffet P, Burdea GC. (2003) Virtual reality technology. Ho-
boken, NJ: Wiley Interscience.
11. Traylor AC, Bordnick PS, Carter BL. Using virtual reality to
assess young adult smokers’ attention to cues. CyberPsy-
chology & Behavior 2009; 12:373–378.
12. Baumann SB, Sayette MA. Smoking cues in a virtual world
provoke craving in cigarette smokers. Psychology of Ad-
dictive Behaviors 2006; 20:484.
13. Giroux I, Faucher-Gravel A, St-Hilaire A, et al. Gambling
exposure in virtual reality and modiﬁcation of urge to
gamble. CyberPsychology, Behavior, & Social Networking
14. Fiore M. (2008) Treating tobacco use and dependence: 2008
update: clinical practice guideline. Washington, DC: US De-
partment of Health and Human Services.
15. Nides M, Leischow S, Sarna L, et al. Maximizing smok-
ing cessation in clinical practice: pharmacologic and be-
havioral interventions. Preventive Cardiology 2007; 10:
16. Reid RD, Quinlan B, Riley DL, et al. Smoking cessation:
lessons learned from clinical trial evidence. Current Opinion
in Cardiology 2007; 22:280–285.
17. Choi J-S, Park S, Lee J-Y, et al. The effect of repeated virtual
nicotine cue exposure therapy on the psychophysiological
responses: a preliminary study. Psychiatry Investigation
18. Girard B, Turcotte V, Bouchard S, et al. Crushing virtual
cigarettes reduces tobacco addiction and treatment dis-
continuation. CyberPsychology & Behavior 2009; 12:477–
19. Moon J, Lee J-H. Cue exposure treatment in a virtual
environment to reduce nicotine craving: a functional
MRI study. CyberPsychology & Behavior 2009; 12:
20. First MB, Gibbon M. (1997) User’s guide for the structured
clinical interview for DSM-IV axis I disorders: SCID-1 cli-
nician version. Washington DC: American Psychiatric
21. Heatherton TF, Kozlowski LT, Frecker RC, et al. The Fager-
¨m test for nicotine dependence: a revision of the Fager-
¨m Tolerance Questionnaire. British Journal of Addiction
22. Hughes JR, Gust SW, Skoog K, et al. Symptoms of tobacco
withdrawal: a replication and extension. Archives of General
Psychiatry 1991; 48:52.
23. Tiffany ST, Drobes DJ. The development and initial valida-
tion of a questionnaire on smoking urges. British Journal of
Addiction 1991; 86:1467–1476.
24. American Psychiatric Association Work Group on Nicotine
Dependence. Practice guideline for the treatment of patients
with nicotine dependence. American Journal of Psychiatry
25. Beck AT, Wright FD. (2011) Cognitive therapy of substance
abuse. New York: Guilford Press.
266 PARK ET AL.
26. Fiore M, Bailey W, Cohen S, et al. Treating tobacco use and
dependence. Rockville, MD: US Department of Health and
Human Services. Public Health Service. 2000:00-0032.
27. Loeber S, Croissant B, Heinz A, et al. Cue exposure in the
treatment of alcohol dependence: effects on drinking out-
come, craving and self-efﬁcacy. British Journal of Clinical
Psychology 2006; 45:515–529.
´guez O, Pericot-Valverde I, Gutie
J, et al. Validation of smoking-related virtual environments
for cue exposure therapy. Addictive Behaviors 2012; 37:
Address correspondence to:
Dr. Jung-Seok Choi
Department of Psychiatry
SMG-SNU Boramae Medical Center
20 Boramae-ro 5-gil
VIRTUAL CET VS. CBT IN NICOTINE DEPENDENCE 267