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Comparison of the Effectiveness of Virtual Cue Exposure Therapy and Cognitive Behavioral Therapy for Nicotine Dependence

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Abstract 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) withdrawal 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 treatment), 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.
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RAPID COMMUNICATION
Comparison of the Effectiveness of Virtual Cue
Exposure Therapy and Cognitive Behavioral
Therapy for Nicotine Dependence
Chan-Bin Park, MA,
1
Jung-Seok Choi, MD, PhD,
1,2
Su Mi Park, MA,
1
Jun-Young Lee, MD, PhD,
1,2
Hee Yeon Jung, MD, PhD,
1,2
Jin-Mi Seol, MA,
1
Jae Yeon Hwang, MD,
1,2
Ah Reum Gwak, BA,
1
and Jun Soo Kwon, MD, PhD
2
Abstract
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.
Introduction
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.
1
Of the numerous factors associated with
treatment outcome, craving is considered a primary trigger
for relapse.
2
Additionally, environmental stimuli (context-
specific stimuli or cues) that are repeatedly associated with
cigarettes are known to promote compulsive smoking.
3,4
Craving and cue reactivity have been conceptualized as
classically conditioned responses.
5
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.
6
CET
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
learning.
7
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.
8
Thus, a virtual reality (VR)
variation on cue exposure treatment (VR-CET) has been de-
veloped as an alternative to CET.
9
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
perspective.
10
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.
11
Recent
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.
12,13
According to clinical practice guideline,
14
there are two
types of counseling and behavioral therapies resulting in
higher success rates: (a) providing smokers with practical
1
Department of Psychiatry, SMG-SNU Boramae Medical Center, Seoul, South Korea.
2
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.
DOI: 10.1089/cyber.2013.0253
262
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.
15,16
However, no study has compared effectiveness of CBT
with that of VR-CET, despite empirical evidence that has been
accumulated.
17–19
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
Participants
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.
20
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.
Procedure
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-
stro
¨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).
Measures
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.
21
This measure,
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.
22
Subjective craving. A 32-item self-report version of the
QSU was administrated to assess subjective craving.
23
A two-
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.
Intervention
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
Fagerstro
¨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
survey.
17
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.
17
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
literature.
24,25
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.
Statistical analysis
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).
Results
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
2
=0.16, p=0.69; week 12: v
2
=0.13, p=0.71;
Fig. 1).
Discussion
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
Time
a
110.17 0.00** Week 0 >week 4,
week12
Condition
b
0.16 0.70 Week 4 <week 12
Time ·condition 0.09 0.91
Expiratory CO
Time 54.82 0.00** Week 0 >week 4,
week 12
Condition 0.06 0.81
Time ·Condition 0.58 0.57
Fagerstro
¨m test
Time 84.39 0.00** Week 0 >week 4,
week 12
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,
week 12
Condition 0.45 0.51 Week 0 >week 12
Time ·Condition 1.09 0.34
Smoking urges
Time 2.55 0.09
Condition 0.01 0.93
Time ·Condition 0.10 0.91
*p<0.05; **p<0.01.
a
Time: week 0 (baseline), week 4 (end of treatment), week 12
(follow-up assessment).
b
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-
dence,
26
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.
27
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-
activity,
28
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
treatment contents.
27
These factors may render treatment
more effective.
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).
14
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.
Conclusions
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.
Acknowledgment
This work was supported by a grant from the SNUH Re-
search Fund (30-2011-0210).
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Dr. Jung-Seok Choi
Department of Psychiatry
SMG-SNU Boramae Medical Center
20 Boramae-ro 5-gil
Dongjak-gu
Seoul 156-707
South Korea
E-mail: choijs73@gmail.com
VIRTUAL CET VS. CBT IN NICOTINE DEPENDENCE 267
... Furthermore, 4 studies investigated the added value of VR-CET to CBT [42,58,61,78]. Culbertson et al [58] compared craving and smoking behaviors between a group of smokers who received CBT and VR-CET and a group of smokers who received CBT and a placebo-VR training. ...
... In addition, 3 studies [42,61,78] did not add a placebo-VR condition but instead compared the craving and smoking behaviors of participants receiving CBT. In the study by Papini et al [78], a group of smokers receiving VR-CET was compared with a group receiving CBT; in the other studies [42,61], both groups received CBT, but only 1 additionally received VR-CET [42,61]. ...
... In addition, 3 studies [42,61,78] did not add a placebo-VR condition but instead compared the craving and smoking behaviors of participants receiving CBT. In the study by Papini et al [78], a group of smokers receiving VR-CET was compared with a group receiving CBT; in the other studies [42,61], both groups received CBT, but only 1 additionally received VR-CET [42,61]. No added value of VR-CET to CBT was found in either of the 3 studies. ...
Article
Full-text available
Background Over the last 2 decades, virtual reality technologies (VRTs) have been proposed as a way to enhance and improve smoking cessation therapy. Objective This systematic review aims to evaluate and summarize the current knowledge on the application of VRT in various smoking cessation therapies, as well as to explore potential directions for future research and intervention development. Methods A literature review of smoking interventions using VRT was conducted. Results Not all intervention studies included an alternative therapy or a placebo condition against which the effectiveness of the intervention could be benchmarked, or a follow-up measure to ensure that the effects were lasting. Virtual reality (VR) cue exposure therapy was the most extensively studied intervention, but its effect on long-term smoking behavior was inconsistent. Behavioral therapies such as a VR approach-avoidance task or gamified interventions were less common but reported positive results. Notably, only 1 study combined Electronic Nicotine Delivery Devices with VRT. Conclusions The inclusion of a behavioral component, as is done in the VR approach-avoidance task and gamified interventions, may be an interesting avenue for future research on smoking interventions. As Electronic Nicotine Delivery Devices are still the subject of much controversy, their potential to support smoking cessation remains unclear. For future research, behavioral or multicomponent interventions are promising avenues of exploration. Future studies should improve their validity by comparing their intervention group with at least 1 alternative or placebo control group, as well as incorporating follow-up measures.
... There are numerous studies in literature which reported the effectiveness of various educational interventions on tobacco cessation. [16][17][18][19][20][21] The findings of this study were similar to those reported in the literature, with subjects from the CBT arm demonstrating reducing frequency of cigarette smoking and lower mean Fagerstrom scale scores compared to the control group. ...
... The mean age of the participants in this study was comparable to the mean age reported in the studies conducted by Farooq et al. [18] and Evins et al. [22] All the study participants were males which is similar to other studies on tobacco cessation counseling conducted by Farooq et al., [18] Park et al., [20] Hill et al. [23] This is one of the first attempts to consider the chief complaint at initial visit to possibly play a role in subject's interest and attention to tobacco cessation counseling, especially in light of the fact that the study participants were care seekers at oral health-care facilities. Chief complaints at the initial visit may act as an effect modifier in the association between the intervention and the outcome of nicotine dependence. ...
Article
Introduction: It is important to introspect if the methods used in tobacco cessation counseling are effective in achieving abstinence and reducing nicotine dependence among tobacco users. The objective of this study was to evaluate the effectiveness of cognitive behavioral therapy (CBT) at tobacco cessation clinics in a teaching dental institution in reducing nicotine dependence among dental patients with the habit of cigarette smoking in comparison to regular health education to quit tobacco. Materials and Methods: This prospective, randomized controlled trial was conducted in a teaching dental institution in the state of Andhra Pradesh. 160 self-reported current cigarette smokers with no tobacco chewing habits participated in the study. 80 each were assigned to the intervention group and control group where CBT for cessation of cigarette smoking and regular health education to quit smoking were provided, respectively. Data relating to frequency of cigarette smoking and nicotine dependence scores using Fagerstrom nicotine dependence scale were collected at baseline. Both the groups were followed up for 4 months in two-monthly intervals. IBM SPSS version 20 software was used for data analysis. Results: While there was no significant difference in the mean nicotine dependence score between the study groups at baseline, a statistically significant difference was observed between the groups at follow up visits. Repeated measures analysis of variance revealed significant reduction in nicotine dependence scores with time in the intervention group (P = 0.004), whereas the differences in the control group between different study time points were not significant (P = 0.39). It was also observed that the frequency of cigarette smoking reduced significantly between the baseline and follow-up visits in the intervention group (Cochran's Q-test; P = 0.028). Conclusion: The findings of this study provide an insight into the fact that CBT as tobacco cessation counseling technique is effective in reducing nicotine dependence among subjects seeking oral health care.
... Inoltre, nello studio di Park e coll. [22], l'efficacia della VR-CET è stata confrontata con la sola TCC, evidenziando che il numero di sigarette fumate, il monossido di carbonio espirato e la dipendenza da nicotina misurata con il test di Fagerström erano significativamente diminuiti in entrambi i gruppi di Reality Cue Exposure Therapy). The study by Pericot-Valverde and coll. ...
... Furthermore, in the study by Park and coll. [22], the efficacy of VR-CET was compared with TCC alone, showing that the number of cigarettes smoked, exhaled carbon monoxide and nicotine dependence measured with the Fagerstrom test were significantly decreased in both study groups, being able to conclude that the efficacy of VR-CET is comparable to classical TCC. In another study by Culbertson and coll. ...
... Since some studies showed a craving reduction through extinction techniques in smoking treatments (Park et al., 2014), and few long-term effects in alcohol users (Mellentin et al., 2017), we can conclude that more attention should be given to methodological issues of the interventions and more studies should be designed to address the effects of renewal, spontaneous recovery, and reinstatement of extinct responses, as well as the failure to extinguish the most salient conditioned cues. All these processes would show the limitations of the technique upon the results. ...
... Social learning theory states that patients must practice coping skills during CET so that they are trained to emit, in the presence of drug CRs, responses that produce consequences that compete with the reinforcing effect of the substance (Rohsenow, Rohsenow et al., 1995). Some studies have isolated CET procedures by focusing on exposure to CSs without developing skills to cope with urges (Park et al., 2014). Other studies performed urge-specific coping skills training combined with CET and observed that the skills taught during CET are correlated with reduced substance use (Marlatt, 1990;Monti et al., 1993;Monti & Rohsenow, 1999;Rohsenow et al., 2001). ...
Chapter
Behaviors that characterize substance use and dependence are ordered and multidetermined, that is, of a complex and multifactorial nature, as defended by the theoretical model of behavior analysis, a science based on the philosophical assumptions of radical behaviorism. The variables influencing the acquisition and maintenance of these behavioral patterns can be described, predicted, and managed; and the functional analysis, being an important assessment tool for the identification and understanding of these various factors involved in these behavioral patterns, describes which circumstances increase the likelihood of recurrence and which consequences control and maintain substance use. The purpose of this chapter is to present the functional analysis in order to equip professionals for a contextualized assessment of behavior, enabling the planning of interventions at the most effective level of prevention and treatment, thus promoting changes in the actions of individuals and, therefore, better indicators of health and quality of life.
... Since some studies showed a craving reduction through extinction techniques in smoking treatments (Park et al., 2014), and few long-term effects in alcohol users (Mellentin et al., 2017), we can conclude that more attention should be given to methodological issues of the interventions and more studies should be designed to address the effects of renewal, spontaneous recovery, and reinstatement of extinct responses, as well as the failure to extinguish the most salient conditioned cues. All these processes would show the limitations of the technique upon the results. ...
... Social learning theory states that patients must practice coping skills during CET so that they are trained to emit, in the presence of drug CRs, responses that produce consequences that compete with the reinforcing effect of the substance (Rohsenow, Rohsenow et al., 1995). Some studies have isolated CET procedures by focusing on exposure to CSs without developing skills to cope with urges (Park et al., 2014). Other studies performed urge-specific coping skills training combined with CET and observed that the skills taught during CET are correlated with reduced substance use (Marlatt, 1990;Monti et al., 1993;Monti & Rohsenow, 1999;Rohsenow et al., 2001). ...
Chapter
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This chapter addresses the theoretical and empirical bases as well as the possible clinical implications of a model that highlights the importance of respondent conditioning and its interaction with operant conditioning in substance use and dependence. Aversive physiological states experienced by the individual are compensatory conditioned responses that “protect the organism” from harmful substance effects. Such compensatory action is responsible for tolerance, withdrawal-like symptoms, craving, and overdose. According to this theory, relapse and active drug-seeking, following abstinence periods, are an effect of reexposure to a drug-conditioned stimulus that elicits and evokes responses that increase motivation to active drug-seeking. There can be failure to extinguish proprieties of the conditioned cues such as its motivating effect that evokes operant responses, reinforced by the substance’s positive effects and the removal of withdrawal-like aversive effects. A possible relapse after treatment has been addressed with the combination of cue exposure therapy (CET) and urge-specific coping skills training, which allows substance users to experience the reduction of drug-conditioned responses while practicing coping skills, along with aiming to generalize these skills beyond clinical settings.
... Using new technologies has the potential to increase the risk potential of gambling (Armstrong et al., 2017), such as the chance to evoke an addiction. It was shown that VR increases several harm-inducing factors, such as dissociation (Aardema et al., 2010) and urge to gamble (Park et al., 2014). Higher harm-inducing factors potentially indicate a higher risk potential of gambling. ...
Article
Full-text available
Slot machines are one of the most played games by players suffering from gambling disorder. New technologies like immersive Virtual Reality (VR) offer more possibilities to exploit erroneous beliefs in the context of gambling. Recent research indicates a higher risk potential when playing a slot machine in VR than on desktop. To continue this investigation, we evaluate the effects of providing different degrees of embodiment, i.e., minimal and full embodiment. The avatars used for the full embodiment further differ in their appearance, i.e., they elicit a high or a low socio-economic status. The virtual environment (VE) design can cause a potential influence on the overall gambling behavior. Thus, we also embed the slot machine in two different VEs that differ in their emotional design: a colorful underwater playground environment and a virtual counterpart of our lab. These design considerations resulted in four different versions of the same VR slot machine: 1) full embodiment with high socio-economic status, 2) full embodiment with low socio-economic status, 3) minimal embodiment playground VE, and 4) minimal embodiment laboratory VE. Both full embodiment versions also used the playground VE. We determine the risk potential by logging gambling frequency as well as stake size, and measuring harm-inducing factors, i.e., dissociation, urge to gamble, dark flow, and illusion of control, using questionnaires. Following a between groups experimental design, 82 participants played for 20 game rounds one of the four versions. We recruited our sample from the students enrolled at the University of Würzburg. Our safety protocol ensured that only participants without any recent gambling activity took part in the experiment. In this comparative user study, we found no effect of the embodiment nor VE design on neither the gambling frequency, stake sizes, nor risk potential. However, our results provide further support for the hypothesis of the higher visual angle on gambling stimuli and hence the increased emotional response being the true cause for the higher risk potential.
... As such, the VR-based Cue Exposure Therapy (CET) uses VR by exposing people to their triggers' addictions to help them develop coping skills and be better equipped to deal with situations that can trigger their addictions. The VR-CET allows inmates to prepare for their social return and reintegration within the prison settings, with similar and possibly higher effectiveness than traditional CET therapies (Giovancarli et al., 2016;Lee et al., 2004;Park et al., 2014 As new generations are born and nurtured in a digital world with significant technical developments, they will undoubtedly embrace technology and oppose conventional learning methods. As a result, VR technology can improve the education of future generations (Harrington et al., 2018). ...
Technical Report
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Virtual Reality for Training Inmates (ViRTI) arises from the need to improve the educational environment and expand the training offer for inmates, who generally have limited access to technical facilities because they are in a closed and restricted environment. Thus, ViRTI aims to use Virtual Reality (VR) technologies by creating virtual environments, compensating for the scarcity of resources (such as laboratories, materials and tools) in prison facilities. In addition, by introducing interactive and gamification features in the learning contents provided to inmates, it will be possible to attract more participants and maintain their motivation, thus reducing drop-out rates. With this project, it will be possible to increasingly encourage the application of content based on VR in prisons, which will collaborate with education and training providers for this purpose. In this way, more inmates will benefit from this added value, as they will develop skills and competencies and acquire knowledge about sectors of the economy where there is a scarce workforce, hence increasing their employability.
... Six sessions of cue exposure therapy also reduced the morning smoking count [41]. Moreover, VR cue-exposure therapy and cognitive behavioral therapy are effective for smoking cessation, although the intervention effects on craving only showed a trend in one study [42]. However, also null findings of cue-exposure therapy on craving have been reported [43]. ...
Article
Full-text available
Due to its high ecological validity, virtual reality (VR) technology has emerged as a powerful tool for mental health research. Despite the wide use of VR simulations in research on mental illnesses, the study of addictive processes through the use of VR environments is still at its dawn. In a systematic literature search, we identified 38 reports of research projects using highly immersive head-mounted displays, goggles, or CAVE technologies to provide insight into treatment mechanisms of addictive behaviors. So far, VR research has mainly addressed the roles of craving, psychophysiology, affective states, cognition, and brain activity in addiction. The computer-generated VR environments offer very realistic, dynamic, interactive, and complex real-life simulations requesting active participation. They create a high sense of immersion in users by combining stereoscopic three-dimensional visual, auditory, olfactory, and tactile perceptions, tracking systems responding to user movements, and social interactions. VR is an emerging tool to study how proximal multi-sensorial cues, contextual environmental cues, as well as their interaction (complex cues) modulate addictive behaviors. VR allows for experimental designs under highly standardized, strictly controlled, predictable, and repeatable conditions. Moreover, VR simulations can be personalized. They are currently refined for psychotherapeutic interventions. Embodiment, eye-tracking, and neurobiological factors represent novel future directions. The progress of VR applications has bred auspicious ways to advance the understanding of treatment mechanisms underlying addictions, which researchers have only recently begun to exploit. VR methods promise to yield significant achievements to the addiction field. These are necessary to develop more efficacious and efficient preventive and therapeutic strategies.
... At 6-and 12-month follow-ups, the CMA and CMS groups obtained similar scores (p > 0.05). Another study by Park et al. (2014) that compared the efficacy of virtual cue exposure therapy (CET) and CBT in patients with nicotine dependence showed that the level of efficacy of CET for the treatment of nicotine dependence is comparable to that of CBT after treatment (12-week follow-up assessment). ...
Article
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Substance use disorders (SUDs) are characterized by a recurrent and maladaptive use of drugs and/or alcohol. Cognitive behavioral therapies (CBTs) comprise different types of interventions: traditional CBT and the more recent “third wave” behavior therapies, such as acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), mindfulness-based cognitive therapy (MBCT), and schema therapy (ST). We searched English-language articles pub- lished between 2014 and present. This review includes randomized controlled trials (RCTs), quasi-RCTs, pilot studies, and reviews of CBTs for SUDs available on PubMed. Results seem to indicate that CBT and MBCT are effective interventions for SUDs; however, the studies showed a high degree of heterogeneity, so no ex- haustive conclusions could be outlined at this time. ACT and DBT in SUD manage- ment are limited to few studies and results are therefore inconclusive.
Conference Paper
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This study aims to examine the effect of cognitive behavioural approach-based (CBA) video presentation on the attitudes towards smoking. It is an experimental design with one intervention and one control group with three measurements, which are the pre, post, and follow-up tests. The study was carried out with undergraduate students. Experimental and control groups each consisted of 16 participants. Data were collected through the Attitudes Towards Smoking Scale. In addition, data were analysed by using Mann Whitney U and Wilcoxon Signed Ranks Tests. The study results revealed a significant difference in the experimental group from pre to post-test. However, there was not a significant difference between the post-test of the experimental and control groups. Nevertheless, the findings showed significant differences between the post-test scores and follow-up scores of the experimental group. It has been determined that BDY-based video presentation strengthens negative attitudes towards smoking, but this effect is not permanent. However, the significant difference between the pre-test and post-test measurements of the experimental group shows that CBA can also be effective in the online environment for cigarette addicts. For this reason, it is important to benefit from cognitive-behavioural approaches in preventive and informative online services regarding cigarette addiction.
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The objective of this article is to review data from studies that used a reinstatement model in rats to elucidate the neural mechanisms underlying relapse to heroin and cocaine seeking induced by exposure to the self-administered drug (drug priming), conditioned drug cues, and stressors. These factors were reported to contribute to relapse to drug use in humans following prolonged abstinence periods. In the reinstatement model, the ability of acute exposure to drug or nondrug stimuli to reinstate drug seeking is determined following training for drug self-administration and subsequent extinction of the drug-reinforced behavior. We will review studies in which pharmacological agents were injected systemically or intracranially to block (or mimic) reinstatement by drug priming, drug cues, and stressors. We also will review studies in which brain lesions, in vivo microdialysis and electrochemistry, and gene expression methods were used to map brain sites involved in relapse to drug seeking. Subsequently, we will discuss theoretical issues related to the processes underlying relapse to drugs and address methodological issues in studies on reinstatement of drug seeking. Finally, the implications of the findings from the studies reviewed for addiction theories and treatment will be discussed. The main conclusion of this review is that the neuronal mechanisms involved in relapse to heroin and cocaine seeking induced by drug priming, drug cues, and stressors are to a large degree dissociable. The data reviewed also suggest that the neuronal events mediating drug-induced reinstatement are to some degree dissociable from those mediating drug reinforcement.
Article
The following executive summary is not intended to stand by itself. The treatment of smoking cessation requires the consideration of many factors and cannot be adequately reviewed in a brief summary. The reader is encouraged to consult the relevant portions of the guideline when specific treatment recommendations are sought. Recommended psychiatric management strategies that all smokers should receive are listed in table 7 (see page 7). Table 8 lists the recommended treatments and their ratings (see page 7). There are a number of promising treatments for nicotine dependence that may be recommended based on individual circumstances. These include intensive behavior therapy [III], educational/supportive groups [III], exercise [III], hypnosis [III], anorectics [III], antidepressants [III], buspirone [III], higher than-normal dose transdermal nicotine [III], mecamylamine [III], nicotine inhaler [III], and sensory replacement [III]. Treatments that cannot be recommended at this time for the treatment of nicotine dependence (either because data indicating lack of efficacy or lack of sufficient evidence supporting efficacy) include: contingency contracting, cue exposure, hospitalization, nicotine fading, physiological feedback, relaxation, 12- step therapy, ACTH, acupuncture, anticholinergics, benzodiazepines, β blockers, glucose, homeopathics, lobeline, naltrexone, nutritional aids, reduction devices, silver nitrate, sodium bicarbonate, and stimulants. Psychiatrists should assess the smoking status of all their patients on a regular basis. If the patient is a smoker, the psychiatrist discusses interest in quitting and gives explicit advice to motivate the patient to stop smoking, including a personalized reason the patient should stop [I]. When possible, advice may come from multiple sources in addition to the psychiatrist; e.g., from other physicians, nurses, social workers, etc. [I]. Written materials may be used as well as face-to-face interventions [II]. Since many psychiatric patients are not ready to quit, the goal of advice will often be to motivate patients to contemplate cessation by reviewing the benefits of quitting, discussing barriers to quitting, and offering support and treatment [III]. If the patient is interested in stopping smoking, a quit date should be elicited, treatment prescribed, and follow-up arranged [II]. The minimal initial treatment for those who wish to quit includes written materials, brief counseling, and follow-up visit or call 1-3 days after the quit date [II]. If the patient has failed serious attempts without formal treatment, failed with nonpharmacological therapies, had serious withdrawal symptoms, or appears highly nicotine dependent, transdermal nicotine is recommended [I]. If the patient prefers or if ad-lib dosing is needed, nicotine gum can be used instead of transdermal nicotine [I]. If used alone, nicotine gum is to be taken on an every-hour basis [I]. If the patient is a highly nicotine-dependent or heavy smoker, higher-dose nicotine gum should be used [I]. Nicotine gum can also be used on an ad-lib basis to supplement transdermal nicotine therapy [II]. If the patient has had trouble stopping smoking for nonwithdrawal reasons (e.g., due to skills deficits), he or she is a candidate for multicomponent behavior therapy [I]. The more effective components of behavior therapy appear to be skills training/relapse prevention; rapid smoking, in which patients inhale cigarette smoke every few seconds; and stimulus control strategies [III]. Some smokers also appear to benefit from group support [III]. Combined behavior therapy and nicotine replacement improves outcome over either treatment alone and is recommended when available and acceptable to the patient [I]; however, attending behavior therapy should not be prerequisite to receiving nicotine replacement therapy [I]. For the smoker who has failed adequate treatment, as described previously, and who is interested in making another attempt to stop smoking, the psychiatrist should assess the adequacy of prior treatments and evaluate the patient for ongoing or residual alcohol, drug, or psychiatric problems that need treatment [II]. If the patient has previously failed an adequate trial of transdermal nicotine and relapse appeared to be withdrawal related, three options are reasonable: a) ad-lib nicotine gum added to transdermal nicotine [II], b) oral or transdermal clonidine [II], or c) nicotine nasal spray [II]. If relapse was due to reasons other than withdrawal (e.g., stress), multicomponent behavior therapy should be considered [I]. If the patient has previously attended such therapy, more intensive individual behavior therapy (e.g., 1-2 times/week for 2-3 weeks) should be considered [III]. Psychiatric and general medical patients who smoke and are on smoke- free wards should receive clear instructions about the no smoking policy, advice to stop smoking, and education about the symptoms and time course of nicotine withdrawal [III]. Those patients who wish to use the smoke free ward to initiate a stop smoking attempt may receive the therapies outlined previously [I]. Patients who do not wish to stop smoking permanently and who evidence nicotine withdrawal may be instructed in behavioral strategies to decrease withdrawal symptoms [III] and provided nicotine replacement (patch or gum) [II]. There is a possibility that smoking cessation might modify psychiatric symptoms (see table 6, page 5) such that it interferes with the diagnosis and treatment of psychiatric disorders (8). Cessation can also dramatically alter blood levels of some psychiatric medications (see table 5, page 5) (8) [II].
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From the Publisher: This in-depth review of current virtual reality technology and its applications provides a detailed analysis of the engineering, scientific and functional aspects of virtual reality systems and the fundamentals of VR modeling and programming. It also contains an exhaustive list of present and future VR applications in a number of diverse fields. Virtual Reality Technology is the first book to include a full chapter on force and tactile feedback and to discuss newer interface tools such as 3-D probes and cyberscopes. Supplemented with 23 color plates and more than 200 drawings and tables which illustrate the concepts described.
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Abstract The urge to gamble is a psychological, physiological, and emotional state involved in the maintenance of pathological gambling. The ability of repeated exposure to a virtual gambling environment to modify the urge to gamble and perceived self-efficacy (PSE) is investigated. Ten video lottery players move throughout a virtual bar with five video lottery terminals five times. The urge to gamble and PSE do not significantly vary during exposure to the gambling environment. However, the desire to gamble significantly increases when passing from the practice environment to the gambling environment. These findings suggest that virtual reality is viable for use in exposure, but that a sole 20-minute session does not set the extinction process into motion. Future studies should be conducted on virtual exposure over the course of several sessions, with the addition of a cognitive restructuring intervention.
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The author summarizes the US Public Health Service report Treating Tobacco Use and Dependence: A Clinical Practice Guideline. The guideline is intended to identify empirically based and validated assessments and treatments for tobacco dependence. The 18-member panel that produced the guideline comprised clinicians, scientists, consumers and methodologists. The panel's major conclusions and recommendations include: (1) Tobacco dependence is a chronic condition that often requires repeated intervention. (2) Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered at least one of these treatments. (3) It is essential that clinicians and health care delivery systems institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a health care setting. (4) Brief tobacco dependence treatment is effective, and every tobacco user should be offered at least brief treatment. (5) There is a strong dose-response relationship between the intensity of tobacco dependence counseling and its effectiveness. (6) Three types of counseling and behavioral therapies were found to be especially effective and should be used with all patients attempting tobacco cessation. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The Structured Clinical Interview for DSM-III-R [Diagnostic and Statistical Manual, Revised] (SCID) is a semistructured interview for making the major Axis I and Axis II diagnoses. It is administered by a clinician or trained mental health professional who is familiar with the DSM-III-R classification and diagnostic criteria (1). The subjects may be either psychiatric or general medical patients or individuals who do not identify themselves as patients, such as subjects in a community survey of mental illness or family members of psychiatric patients. The language and diagnostic coverage make the SCID most appropriate for use with adults (age 18 or over), but with slight modification, it may be used with adolescents. (PsycINFO Database Record (c) 2012 APA, all rights reserved)