November 2007

Play on!

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The Virtual Reality Medical Center (VRMC) has created an Internet-based Virtual Reality (VR) game that helps adolescents cease smoking.  This interactive program uses cue exposure therapy (CET) to treat addictive behaviors. Furthermore, VRMC's teen smoking Cessation program educates adolescents on how to effectively avoid situations that cause cravings. In addition, repeated exposure to problematic triggers eventually leads to desensitization.

Virtual Environment (VE) Overview

The VRMC Teen Smoking VE consists of two major regions: home and school. The home is comprised of two floors: The first floor is the garage, the one above has a bedroom, kitchen, living room and bathroom (refer to Figures 1a-b). The school environment includes the classroom, restroom, and cafeteria area (refer to Figures 1c-d).

At the start of the program, the user is placed in his/her bedroom where he/she must select a quit date from the provided calendar before being able to participate in other activities. A smoking cessation tip is to remove all smoking paraphernalia from the environment if possible, which is what the player must do in the game to help decrease their craving level.  In the first VE, smoking cues are placed around the teenager's home.  In these cases, users can choose to “smoke,” “ignore,” or “throw away” objects, such as a pack of cigarettes, which increases their cravings if not removed.  In the second environment, at school, they deal with pressure from their peers to smoke. In those scenes, the user has the option of refusing, considering, or accepting the offer to smoke. When the user turns down cigarettes offered by peers, the user is faced with the challenge of suppressing the craving by playing a mini game.  If he/she wins the randomly selected game, the user has successfully denied the craving.  However, if the user loses, this translates to him/her giving into the craving and smoking, which also leads to the resetting of the smoke-free day counter.

The presence of the “lungs” icon in the lower left corner of the screen represents the current lung condition of the user. The more the user smokes, the darker the lungs become. The status bar directly below it indicates the user's current “stamina” level. Each day, the bar starts off full and gradually decreases as the day goes on. Participating in activities, like exercising, also uses up stamina. Furthermore, the rate of stamina decrease is dependent on the lung condition. The healthier the lungs (brighter), the slower the stamina rate decreases. When the stamina falls too low, the user must either rest by taking a nap or refuel the body by making and eating a sandwich. On the lower right corner is the “craving” status bar which starts off empty. It indicates the user's current craving level to smoke. When a user approaches smoking cues like an ashtray, alcohol, or coffee, the craving bar goes up.  However, when users participate in an activity in an effort to distract themselves from the desire to smoke, the result is a reduction in cravings.  When the user's craving level approaches the maximum, the user's vision (the visuals on the screen) will begin to blur and flash red, acting as a warning sign.  Under these circumstances, the user can either participate in an activity or take a smoke in order to alleviate the craving. 

Ultimately, the goal of the program is for users to remain smoke free in both environments for as long as possible. Rewards and other forms of encouragement are awarded after the user has maintained a smoke-free regimen following certain time periods.

Methodology

A research study was conducted with 15 participants, for sessions of 15 minutes each, after all regulatory approvals (IRB) were received. The Teen Smoking Pre/Post Test Questionnaire was used to assess the adolescent's knowledge related to the cessation of smoking.  Subjects who fully agreed with a question rated it with a 1, fully disagreeing led to a rating of 10, and ratings from 2-9 delineated a response either associated with somewhat agreeing or disagreeing. Scores were summed, signifying each participant's knowledge.

Results

The data were reviewed and analyzed. Overall, the data collected suggests the development of healthier habits following game play.

In the program, subjects can choose to do physical exercise or to smoke. Before they played the game, 40% of the users disagreed with the statement that “physical exercise makes you want to smoke,” but after they played the game, 60% of them disagreed. 

The environment also allowed subjects to choose whether they wanted to smoke or to do another activity (other than exercise) to occupy their time. Before the game was played, 86.7% of participants agreed with the following statement: “It helps to keep busy when you have a hard time quitting smoking,” whereas after the game was played, 93.3% of participants agreed (refer to figures 2a and 2b).  

Additionally, the option of selecting a quit date is offered to subjects. When asked whether setting a quit date would aid in actually quitting, 60% of subjects agreed that it would aid in quitting prior to playing the game, whereas 40% were neutral. After playing the game, however, 66.7% agreed that setting a quit date helps you to quit, whereas 6.7% disagreed, and 26.7% remained neutral.

To test the degree of realism experienced by the participants in the VE, a Presence and Realism Questionnaire was also administered. The higher the score, the more realistic the participant felt the VE was.

The following data were collected as self-rated scores on a scale from one to seven: auditory involvement, visual involvement, and consistency between the VR world and the natural environment. The score differences between the before and after training were treated as a new variable. Linear regression was applied to detect the trends between score differences and auditory and visual involvement and consistency of VR environment.

It was shown that the more auditory and visual involvement the subjects felt, and if the subjects felt that the VR environment was consistent with the natural environment, those subjects did better in the questionnaires, which was a measurement to detect the overall likelihood for subjects to quit smoking. Positive trends were detected between auditory involvement and score differences, visual involvement and score differences, and consistency and score differences.

Summary and Conclusions

VRMC has thus successfully created an Internet based virtual interactive environment in an effort to curb teen smoking.  This teen smoking cessation program is Adobe Flash Player 9.0 based and can be easily accessed at www.vrphobia.com/teensmoking.  Furthermore, after participating in the program, subjects agreed that setting a quit date helps you to quit; and keeping busy and performing physical activities can aid with distraction from smoking.  Participants also agreed that the virtual setting provided an environment with realistic visual and auditory effects and no occurrence of side effects.

VRMC and its affiliate in Brussels, Virtual Reality Medical Institute (VRMI), have initiated conversations with European partners who are committed to help bring the Teen Smoking Cessation project to their countries. VRMC has also established an agreement to deliver the software via the Internet.  

For the complete version of the article with references log on to  www.ehealthonline.org 

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