Validation of smoking-related virtual environments for cue exposure therapy

Virtual reality cue exposure therapy for tobacco relapse prevention: a comparative study with standard intervention

BACKGROUND

Successful interventions have been developed for smoking cessation although the success of smoking relapse prevention protocols has been limited. Cognitive behavioural therapy (CBT) in particular has been hampered by a high relapse rate. Because relapse can be due to conditions associated with tobacco consumption (such as drinking in bars with friends), virtual reality cue exposure therapy (VRCE) can be a potential tool to generate 3D interactive environments that simulate risk situations for relapse prevention procedures.

METHODS

To assess the effectiveness of VRCE with CBT, a comparative trial involving 100 smoking abstinent participants was designed with all required virtual environments (VE) created with an inexpensive graphic engine/game level editor.

RESULTS

Outcome measures confirmed the immersive and craving eliciting effect of these VEs. Results demonstrated that more participants in the VRCE group did not experience smoking relapse and that VRCE is at least as efficacious as traditional CBT in terms of craving reduction and decrease in nicotine dependence. Dropout and relapse rate in the VRCE group was noticeably lower than the CBT group. Aside from mood scores, no significant differences were found regarding the other scales.

CONCLUSION

The present clinical trial provides evidence that VRCE was effective in preventing smoking relapse. Improvement in technology and methodology for future research and applications is delineated.

Modeling cue-exposure therapy for alcohol use disorder in rhesus monkeys: Effects of putative cognitive enhancers

BACKGROUND

Cue-exposure therapy (CET) is an effective approach for anxiety-related disorders, but its effectiveness for substance use disorders is less clear. One potential means of improving CET outcomes is to include a cognitive-enhancing pharmacotherapy. This study evaluated d-cycloserine (DCS) and RY-023, putative cognitive enhancers targeting glutamate and GABA systems, respectively, in a monkey model of CET for alcohol use disorder.

METHODS

Male rhesus monkeys (n = 4) underwent multiple cycles of the CET procedure. During baseline (Phase 1), monkeys self-administered an ethanol solution under a fixed-ratio schedule and limited access conditions such that every 5th response in a 3-h session resulted in 30-s access to a drinking spout and a change in ethanol-paired cue lights from white to red. Behavior then was extinguished (Phase 2) by omitting the ethanol solution yet retaining the ethanol-paired stimulus lights. Monkeys also received injections of vehicle, DCS (3 mg/kg), a partial agonist at the glycine modulatory site on glutamatergic NMDA receptors, or the α5GABAA receptor-selective inverse agonist RY-023 (0.03 or 0.3 mg/kg). Once responding declined, monkeys underwent a cue reactivity test (Phase 3), and then returned to self-administration the following day to assess reacquisition (Phase 4).

RESULTS

Through multiple cycles, self-administration remained stable. Compared to vehicle, DCS facilitated extinction of ethanol seeking (Phase 2) and delayed reacquisition of ethanol self-administration (Phase 4). In contrast, RY-023 facilitated extinction (Phase 2) and reduced cue reactivity (Phase 3).

CONCLUSIONS

Adjunctive pharmacotherapy can improve CET outcomes, but the choice of pharmacotherapy should be dependent on the outcome of interest.

Virtual reality in the diagnostic and therapy for mental disorders: A systematic review

BACKGROUND

Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders.

OBJECTIVE

To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders.

DATA SOURCE

Systematic literature searches via PubMed (last literature update: 9^th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders.

ELIGIBILITY CRITERIA

To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology.

STUDY EVALUATION

For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria.

RESULTS

Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder.

CONCLUSION

While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application.

REVIEW REGISTRATION

PROSPERO register CRD42020188436.

FUNDING

The review was funded by budgets from the University of Bonn. No third party funding was involved.

Smokers’ Self-Report and Behavioral Reactivity to Combined Personal Smoking Cues (Proximal + Environment + People): A Pilot Study

Cue reactivity (CR) among smokers exposed to smoking-related stimuli, both proximal (e.g., cigarettes, lighter) and distal (environments, people), has been well-demonstrated. Furthermore, past work has shown that combining proximal smoking cues with smoking environment cues increases cue-provoked craving and smoking behavior above that elicited by either cue type alone. In this pilot study, we examined the impact of combining three personal cues, proximal + environment + people, on subjective and behavioral cue reactivity among smokers. To further understand the impact of this method, we also tested reactivity under the conditions of both smoking satiety and deprivation. In addition, we examined the extent to which cue-induced craving predicted immediate subsequent smoking. Fifteen smokers completed six sessions, of which two focused on the intake and development of personal cues and four involved personal cue reactivity sessions: (1) deprived, smoking cue combination, (2) deprived, nonsmoking cue combination, (3) sated, smoking combination, and (4) sated, nonsmoking cue combination. Cue-provoked craving was greater and smokers were quicker to light a cigarette and smoked more during their exposure to smoking rather than nonsmoking cues and in deprived compared to sated conditions, with no interaction between these variables. While deprived, greater cue-provoked craving in response to smoking cues was correlated with a quicker latency to light a cigarette. This work supports the feasibility of presenting three personal smoking-related combinations of cues within a cue reactivity paradigm and highlights the robust reactivity that this methodology can evoke in smokers.

Assessing the attentional bias of smokers in a virtual reality anti-saccade task using eye tracking

INTRODUCTION

Cognitive biases (among them attentional bias, AB) are considered an important factor in the development, maintenance, and recurrence of addiction. However, traditional paradigms to measure AB have been criticized regarding external validity and methodical issues. Therefore, and because the neurophysiological correlates of anti-saccade tasks are known, we implemented a novel smoking anti-saccade task in virtual reality (VR) to measure AB and inhibitory control in different contexts and with higher ecological validity.

METHODS

Smokers (n = 20) and non-smokers (n = 20) were tested on a classic pro- and anti-saccade task, a VR anti-saccade task and a VR attention fixation task (all containing smoking-related and neutral stimuli) while eye-tracking data was collected. Two VR contexts (park and office room) were applied.

RESULTS

Saccade latencies were significantly higher for the smoking group in the VR anti-saccade task. However, this effect did not differ between smoking-related and neutral stimuli, thus overall no AB was observed. Instead, AB was only present in the park context. Additionally, saccade latencies and error rates were significantly higher in the park context.

CONCLUSIONS

Results indicate impaired inhibitory control in smokers relative to non-smokers. The lack of evidence for a general AB might be due to the lower severity of smoking dependence in the smoking sample. Instead, results suggest context specificity of AB. Implications for smoking cessation interventions in the field of inhibitory control training and attention bias modification are discussed.

Virtual Reality Technology Use in Cigarette Craving and Smoking Interventions (I "Virtually" Quit): Systematic Review

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.

Clinical Relevance of Immersive Virtual Reality in the Assessment and Treatment of Addictive Disorders: A Systematic Review and Future Perspective

(1) Background: Virtual reality (VR) has been investigated in a variety of psychiatric disorders, including addictive disorders (ADs); (2) Objective: This systematic review evaluates the current evidence of immersive VR (using head-mounted displays) in the clinical assessment and treatment of ADs; (3) Method: PubMed and PsycINFO were queried for publications up to November 2020; (4) Results: We screened 4519 titles, 114 abstracts and 85 full-texts, and analyzed 36 articles regarding the clinical assessment (i.e., diagnostic and prognostic value; n = 19) and treatment (i.e., interventions; n = 17) of ADs. Though most VR assessment studies (n = 15/19) showed associations between VR-induced cue-reactivity and clinical parameters, only two studies specified diagnostic value. VR treatment studies based on exposure therapy showed no or negative effects. However, other VR interventions like embodied and aversive learning paradigms demonstrated positive findings. The overall study quality was rather poor; (5) Conclusion: Though VR in ADs provides ecologically valid environments to induce cue-reactivity and provide new treatment paradigms, the added clinical value in assessment and therapy remains to be elucidated before VR can be applied in clinical care. Therefore, future work should investigate VR efficacy in randomized clinical trials using well-defined clinical endpoints.

Virtual Reality-Based Treatment Approaches in the Field of Substance Use Disorders

Purpose

Substance use disorders (SUD) are burdening chronic conditions characterized by high relapse rates despite severe negative consequences. Substance-related cues that elicit craving by means of automatic physiological and behavioural responses have long been suggested to predict relapse. One major mechanism contributing to relapse behaviour are cue-induced behavioural approach tendencies towards the addictive agent. Recently, there has been an emerging interest in virtual reality (VR)-based approaches to assess and modify craving and its related responses. This review aims at elucidating (1) VR techniques applied in the field of SUD, (2) VR as an induction/assessment tool for biopsychological correlates of craving and (3) VR-based therapeutic approaches.

Findings

There is an emerging number of studies focusing on different substances of abuse incorporating VR in craving induction/assessment as well as therapy. Despite some limitations as missing of randomized controlled clinical trials with large samples and missing data on the long-term effects of VR treatment, the VR approach showed consistent results in eliciting and reducing craving across different substances.

Summary

This review suggests virtual reality as a promising tool for the assessment and treatment of craving among individuals with substance use disorders. Because of its ecological validity, VR unifies the benefits of a laboratory setting with the advantages of a realistic environment. Further studies with large samples and randomized controlled clinical trials using more homogenous VR techniques as well as assessment of objective biophysiological craving markers are required.

A virtual reality study on postretrieval extinction of smoking memory reconsolidation in smokers

Exposure to smoking-related stimuli may induce the reconsolidation of smoking-related memories in smokers. Research has proposed that extinction applied after the retrieval of a smoking memory may inhibit reconsolidation and prevent craving. The aim of this study was to test the effect of postretrieval extinction (PRE) on the reconsolidation of smoking memory by using a virtual reality (VR) simulation in smokers. On the day 1 session, the study exposed 46 smokers to a neutral and then to a smoking VR scenario under a fixed-block protocol. On day 2, the study randomized participants into three groups (G) and exposed them to a 15-s VR immersion in smoking (G1, G3) or neutral (G2) scenario for memory retrieval. After 15 min, the study exposed G1 and G2 to a VR PRE during the temporal window of memory vulnerability, whereas the study exposed G3 to extinction immediately after retrieval. On day 3, the study exposed all groups to neutral and smoking scenarios similar to day 1. All groups significantly increased craving for cigarettes after exposure to the smoking scenario on day 1 (p < 0.01). On day 3, VR PRE after a 15-second VR smoking memory retrieval was able to inhibit reconsolidation in G1, but not in G3 exposed to PRE before the window of vulnerability, or in G2 not exposed to the smoking memory retrieval. These findings show the superiority of VR PRE after smoking memory retrieval compared to a standard extinction procedure.

Smoking-related cue reactivity in a virtual reality setting: association between craving and EEG measures

BACKGROUND

Cue-reactivity is the array of responses that smokers exhibit when exposed to conditioned and contextual stimuli previously associated to substance use. The difficulty to experimentally recreate the complexity of smokers' spatial experience and context requires more ecological models. Virtual reality (VR) creates a state of immersion close to reality allowing controlled assessments of behavioral responses. To date, no studies investigated brain activation associated to smoking cue-reactivity in VR using electroencephalography (EEG).

AIMS

To investigate whether a VR cue-reactivity paradigm (a) may increase smoking craving, (b) is feasible with EEG recording, and (c) induces craving levels associated to EEG desynchronization.

METHODS

Smokers (N = 20) and non-smokers (N = 20) were exposed to neutral and smoking-related VR scenarios, without and with smoking conditioned stimuli, respectively. EEG was recorded from occipital and parietal leads throughout the sessions to assess alpha band desynchronization. Smoking and food craving and presence visual analogue scales (VAS) were assessed during the session.

RESULTS

To be smoker, but not non-smoker, significantly influenced smoking craving VAS induced by smoking cue VR but not by neutral VR. No significant food craving changes was observed during the VR sessions. The new finding was that EEG alpha band power in posterior leads was significantly increased by the smoking context scenario only in smokers, and that the degree of smoking (i.e., heavy vs. light) was significantly associated to this neurophysiological measure.

CONCLUSIONS

This study demonstrated, for the first time, the feasibility of EEG recording in a VR setting, suggesting that EEG desynchronization may be a neurophysiological marker of smoking cue-reactivity.

(No) escape from reality? Cigarette craving in virtual smoking environments

Cue-Exposure Therapy (CET) is considered an effective strategy to combat cigarette cravings and smoking relapses, but evidence is mixed. In this lab-based experimental study, we manipulated levels of realism for smoking scenarios in Virtual Environments (VE) and randomly exposed smokers and recent-quitters to one of two versions (low versus high realism) of these scenarios. Prior and after scenario exposure, valid measures of cigarette craving were obtained. Prior to exposure, we assessed nicotine dependence and smoking status (current smokers versus recent-quitter). Within-subject repeated measures analysis of covariance showed that there was an interaction of experimental condition with smoking status on cigarette craving. Amongst recent-quitters, high realistic scenarios produced stronger increases in craving than low realistic scenarios, but this effect was reversed in current smokers. It is concluded that VE technologies are a potentially relevant tool for smoking CET that warrant further exploration.

Real-world unassisted quit success and related contextual factors: a population-based study of Chinese male smokers

OBJECTIVES

To examine the association of exposure to secondhand smoke (SHS) and tobacco advertising with unassisted smoking cessation among Chinese male smokers.

METHODS

A questionnaire was administered to 6500 male adult smokers from six cities in China selected in a cross-sectional multistage sampling design. The survey collected self-reported demographic characteristics, smoking and cessation status, SHS exposure and tobacco advertising exposure, with 5782 valid questionnaires included in this study. Multiple logistic regression analysis was used to assess the association of unassisted smoking cessation with exposure to SHS and tobacco advertising.

RESULTS

42.1% of smokers who made unassisted quit attempts achieved abstinence (95% CI 32.5% to 51.7%). SHS (adjusted OR (aOR) 0.36; 95% CI 0.18 to 0.71; p=0.033) and tobacco advertising exposure (aOR 0.63; 95% CI 0.37 to 0.95; p=0.039) were negatively associated with unassisted smoking cessation.

CONCLUSION

The vast majority of Chinese male smokers rely on unassisted methods to quit smoking. Success prevalence is high, which is very beneficial to health. This study suggests that exposure to secondhand smoking and tobacco advertising hinders the success of unassisted cessation. These findings speak to the need for environmental tobacco control measures to promote unassisted smoking cessation among Chinese adult male smokers.

Extended Reality in Patient Care and Pharmacy Practice: A Viewpoint

The evolution of technology has given practitioners and educators more tools to better treat, manage, and educate both patients and future pharmacists. The objective of this viewpoint publication is to describe the current use of extended reality (XR) in pharmacy and propose ways in which pharmacy practice and education may benefit from incorporation of this technology. While these tools have been used for decades by many other professions, pharmacy is starting to adopt XR in professional and educational practice. XR (virtual reality, mixed reality, and augmented reality) is being used in various aspects of pharmacy care and education, such as pain management, diabetes self-care, cross-checking of prescriptions, treatments for addiction, and (in limited ways) patient and pharmacy education. There is great potential for further integration of XR into pharmacy practice and pharmacy education to ultimately improve patient care and education as well as pharmacy education.

Virtual Reality (VR) in Assessment and Treatment of Addictive Disorders: A Systematic Review

Background: Substance Use Disorder (SUD) and behavioral addictions are common and require a multidisciplinary approach. New technologies like Virtual Reality could have the potential to improve assessment and treatment of these disorders.

Objective: In the present paper, we therefore present an overview of Virtual Reality (Head Mounted Devices) in the field of addiction medicine for craving assessment and treatment.

Method: We conducted a systematic review by querying PubMed database for the titles of articles published up to March 2019 with the terms [virtual] AND [addictive] OR [addiction] OR [substance] OR [alcohol] OR [cocaine] OR [cannabis] OR [opioid] OR [tobacco] OR [nicotine] OR [methamphetamine] OR [gaming] OR [gambling].

Results: We screened 319 abstracts and analyzed 37 articles, dividing them into two categories, the first for assessment of cue reactivity (craving, psychophysiological response and attention to cue) and the second for intervention, each drug (nicotine, cocaine, alcohol, cannabis, gambling) being detailed within each category.

Conclusions: This overview suggest that VR provide benefits in the assessment and treatment of substance use disorders and behavior addictions and achieve high levels of ecological validity. While, craving provocation in VR is effective across addiction disorders, treatments based exclusively on virtual exposure to drug related cues as shown heterogenous results.

Extended Reality in Patient Care and Pharmacy Practice: A Viewpoint

The evolution of technology has given practitioners and educators more tools to better treat, manage, and educate both patients and future pharmacists. The objective of this viewpoint publication is to describe the current use of extended reality (XR) in pharmacy and propose ways in which pharmacy practice and education may benefit from incorporation of this technology. While these tools have been used for decades by many other professions, pharmacy is starting to adopt XR in professional and educational practice. XR (virtual reality, mixed reality, and augmented reality) is being used in various aspects of pharmacy care and education, such as pain management, diabetes self-care, cross-checking of prescriptions, treatments for addiction, and (in limited ways) patient and pharmacy education. There is great potential for further integration of XR into pharmacy practice and pharmacy education to ultimately improve patient care and education as well as pharmacy education.

A virtual reality counterconditioning procedure to reduce methamphetamine cue-induced craving

The present work developed a virtual reality (VR) counterconditioning procedure (VRCP), and investigated its efficacy in treatment of cue-induced craving in individuals with methamphetamine (METH) dependence. In study 1, thirty-one patients diagnosed with METH dependence received VRCP, while twenty-nine METH-dependent patients in waiting-list group did not. In study 2, the VRCP was computerized as a VR treatment system. Six-hundred and twelve abstinent individuals with a history of METH dependence received the computerized VRCP, while two-hundred seventy-six abstinent individuals with a history of METH dependence in waiting-list group did not. Patients with METH dependence who received VRCP showed a significantly larger decrease on the score of METH-craving and METH-liking from baseline to follow-up assessments, compared to those who did not received VRCP. Participants received VRCP showed a significantly larger decrease in HRV indexes on time domain and non-linear domain from baseline to follow-up assessments during exposure to VR cues, compared to those in waiting-list group. These findings indicate that the counterconditioning procedure under VR environment may be a useful strategy in suppressing cue-induced reactivity for patients with METH dependence.

Detection of patients with methamphetamine dependence with cue-elicited heart rate variability in a virtual social environment

In the present study, we developed a methamphetamine (METH)-related virtual social environment to elicit subjective craving and physiological reactivity. Sixty-one male patients who were abstinent from METH use and 45 age-matched healthy males (i.e., normal controls) were recruited. The physiological electrocardiogram (ECG) signals were recorded before (resting-state condition) and during viewing of a METH-cue video in the virtual environment (cue-induced condition). The cue-induced subjective craving was measured with a visual analogue scale (VAS) for patients with METH dependence. The results indicated that the cue-induced condition elicited significant differences in heart rate variability (HRV) between patients with METH dependence and normal controls. The changes of HRV indexes on time domain and non-linear domain from the resting-state condition to the cue-induced condition were positively correlated with the score on VAS of METH craving. Using a supervised machine learning algorithm with the features extracted from HRV changes, our results showed that the discriminant model provided a high predictive power for distinguishing patients with METH dependence from normal controls. Our findings support that immersing subjects with METH dependence in a METH-related virtual social environment can successfully induce physiological reactivity, and cue-induced physiological signal changes may have a potential implication in clinical practice.

Virtual Reality Cue Refusal Video Game for Alcohol and Cigarette Recovery Support: Summative Study

BACKGROUND

New technologies such as virtual reality, augmented reality, and video games hold promise to support and enhance individuals in addiction treatment and recovery. Quitting or decreasing cigarette or alcohol use can lead to significant health improvements for individuals, decreasing heart disease risk and cancer risks (for both nicotine and alcohol use), among others. However, remaining in recovery from use is a significant challenge for most individuals.

OBJECTIVE

We developed and assessed the Take Control game, a partially immersive Kinect for Windows platform game that allows users to counter substance cues through active movements (hitting, kicking, etc).

METHODS

Formative analysis during phase I and phase II guided development. We conducted a small wait-list control trial using a quasi-random sampling technique (systematic) with 61 participants in recovery from addiction to alcohol or tobacco. Participants used the game 3 times and reported on substance use, cravings, satisfaction with the game experience, self-efficacy related to recovery, and side effects from exposure to a virtual reality intervention and substance cues.

RESULTS

Participants found the game engaging and fun and felt playing the game would support recovery efforts. On average, reported substance use decreased for participants during the intervention period. Participants in recovery for alcohol use saw more benefit than those in recovery for tobacco use, with a statistically significant increase in self-efficacy, attitude, and behavior during the intervention. Side effects from the use of a virtual reality intervention were minor and decreased over time; cravings and side effects also decreased during the study.

CONCLUSIONS

The preliminary results suggest the intervention holds promise as an adjunct to standard treatment for those in recovery, particularly from alcohol use.

Influence of point-of-sale tobacco displays and plain black and white cigarette packaging and advertisements on adults: Evidence from a virtual store experimental study

INTRODUCTION

We examined the potential impact of banning tobacco displays and mandating plain packaging and cigarette advertisements at the point of sale (POS) on adult outcomes.

METHODS

A virtual convenience store was created with scenarios in which the tobacco product display was either fully visible (status quo) or enclosed behind a cabinet (display ban), and cigarette packs and advertisements were either in full color (status quo) or black and white, text only (plain). A national convenience sample of 1313 adult current smokers and recent quitters was randomized to 1 of 4 conditions and given a shopping task to complete in the virtual store. Main outcomes were participants' self-reported urge to smoke and tobacco purchase attempts in the virtual store.

RESULTS

Compared with recent quitters in the status quo conditions, recent quitters in the display ban condition had lower urges to smoke (β=-4.82, 95% CI=-8.16--1.49, p<0.01). Compared with current smokers in the status quo conditions, smokers in the display ban conditions were less likely to attempt to purchase cigarettes in the virtual store (OR=0.05, 95% CI=0.03-0.08, P<0.01). Smokers exposed to plain packs and ads were significantly less likely to attempt to purchase cigarettes (OR=0.31, 95% CI=0.20-0.47, P<0.01) than those exposed to color packs and ads.

CONCLUSIONS

Policies that ban the display of tobacco products or require plain packaging and advertising at the POS may help reduce adult smoking.

Virtual reality cue exposure for the relapse prevention of tobacco consumption: a study protocol for a randomized controlled trial

Background

Successful interventions have been developed for smoking cessation, but the success of smoking relapse prevention interventions has been limited. In particular, cognitive behavioural therapy (CBT) has been hampered by a high relapse rate. Because relapses can be due to the presence of conditions associated with tobacco consumption (such as drinking in bars with friends), virtual reality exposure therapy (VRET) can generate synthetic environments that represent risk situations for the patient in the context of relapse prevention. The primary objective of this study is to evaluate the effectiveness of CBT coupled with VRET, in comparison to CBT alone, in the prevention of smoking relapse. The secondary objectives are to assess the impact of CBT coupled with VRET on anxiety, depression, quality of life, self-esteem and addictive comorbidities (such as alcohol, cannabis, and gambling). A third objective examines the feasibility and acceptability of VR use considering elements such as presence, cybersickness and number of patients who complete the VRET program.

Method/design

The present study is a 14-month (2 months of therapy followed by 12 months of follow-up), prospective, comparative, randomized and open clinical trial, involving two parallel groups (CBT coupled with VRET versus CBT alone). The primary outcome is the proportion of individuals with tobacco abstinence at 6 months after the end of the therapy. Abstinence is defined by the total absence of tobacco consumption assessed during a post-test interview and with an apparatus that measures the carbon monoxide levels expired. A total of 60 individuals per group will be included.

Discussion

This study is the first to examine the efficacy of CBT coupled with VRET in the prevention of smoking relapse. Because VRET is simple to use and has a low cost, this interactive therapeutic method might be easily implemented in clinical practice if the study confirms its efficacy.

Trial registration

ClinicalTrials.gov Identifier: NCT02205060 (registered 25 July 2014).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1224-5) contains supplementary material, which is available to authorized users.

Ceftriaxone attenuates cocaine relapse after abstinence through modulation of nucleus accumbens AMPA subunit expression

Using the extinction-reinstatement model of cocaine relapse, we and others have demonstrated that the antibiotic ceftriaxone attenuates cue- and cocaine-primed reinstatement of cocaine-seeking. Reinstatement is contingent on the release of glutamate in the nucleus accumbens core (NAc) and manipulations that reduce glutamate efflux or block post-synaptic glutamate receptors attenuate reinstatement. We have demonstrated that the mechanism of action by which ceftriaxone attenuates reinstatement involves increased NAc GLT-1 expression and a reduction in NAc glutamate efflux during reinstatement. Here we investigated the effects of ceftriaxone (100 and 200 mg/kg) on context-primed relapse following abstinence without extinction training and examined the effects of ceftriaxone on GluA1, GluA2 and GLT-1 expression. We conducted microdialysis during relapse to determine if an increase in NAc glutamate accompanies relapse after abstinence and whether ceftriaxone blunts glutamate efflux. We found that both doses of ceftriaxone attenuated relapse. While relapse was accompanied by an increase in NAc glutamate, ceftriaxone (200 mg/kg) was unable to significantly reduce NAc glutamate efflux during relapse despite its ability to upregulate GLT-1. GluA1 was reduced in the NAc by both doses of ceftriaxone while GluA2 expression was unchanged, indicating that ceftriaxone altered AMPA subunit composition following cocaine. Finally, GLT-1 was not altered in the PFC by ceftriaxone. These results indicate that it is possible to attenuate context-primed relapse to cocaine-seeking through modification of post-synaptic receptor properties without attenuating glutamate efflux during relapse. Furthermore, increasing NAc GLT-1 protein expression is not sufficient to attenuate glutamate efflux.

The Use of Virtual Reality in the Production of Cue-Specific Craving for Cigarettes: A Meta-Analysis

INTRODUCTION

The cue-reactivity procedure has demonstrated that smokers respond with increases in subjective craving in the presence of smoking-related cues. Virtual reality is an emerging mode of cue presentation for cue-reactivity research. Despite the successful implementation of virtual reality during the last decade, no systematic review has investigated the magnitude of effects across studies.

METHODS

This research systematically reviewed findings from studies using virtual reality in cigarette craving assessment. Eligible studies assessed subjective craving for cigarettes in smokers exposed to smoking-related and neutral environments. Cohen's d was used to assess differences in craving between smoking-related and nonsmoking-related virtual environments. A random effects approach was used to combine effect sizes.

RESULTS

A total of 18 studies involving 541 smokers was included in the final analyses. Environments with smoking-related cues produced significant increases in craving relative to environments without smoking-related cues. The mean overall effect size (Cohen's d) was 1.041 (SE = 0.12, 95% CI = 0.81 to 1.28, Z = 8.68, P < .001).

CONCLUSIONS

The meta-analysis suggested that presentations of smoking cues through virtual reality can produce strong increases in craving among cigarette smokers. This strong cue-reactivity effect, which was comparable in magnitude to the craving effect sizes found with more conventional modes of cue presentation, supports the use of virtual reality for the generation of robust cue-specific craving in cue-reactivity research.

Individual variables related to craving reduction in cue exposure treatment

INTRODUCTION

Although extensive research has demonstrated that cigarette craving can be effectively attenuated, very few studies have explored associations between individual variables and craving reduction. This study explored whether individual characteristics predict craving decreases during virtual reality cue exposure treatment (VR-CET).

METHOD

Participants were 41 treatment-seeking smokers (73% women) with a mean age of 39.4 (SD=13.2), who had been smoking 15.0 (SD=7.1) cigarettes per day for 20.0 (SD=10.7) years. Their mean score on the Fagerström Test of Nicotine Dependence (FTND) was 4.8 (SD=2.3). Participants completed five cue exposure sessions using virtual reality for smoking cessation over a five-week period. The percentage of reduction in craving was calculated by comparing self-reported craving after the first and last exposure sessions. Sociodemographic characteristics (gender, age, years of education and marital status), tobacco-related [duration of daily smoking, cigarettes per day, FTND and Nicotine Dependence Syndrome Scale (NDSS)] and psychological characteristics [depressive symptoms (Beck's Depression Inventory-Second Edition, BDI-II), impulsiveness (delay discounting) and anxiety (State-Trait Anxiety Inventory, STAI)] were examined as possible predictors for craving reductions.

RESULTS

Multiple regression revealed that greater decreases in craving were associated with younger age (β=-.30, p=.043), cigarettes smoked per day (β=.30, p=.042), higher values on delay discounting (β=.34, p=.020) and higher BDI-II scores (β=.30, p=.035).

CONCLUSION

These findings suggest that smokers with certain individual characteristics may benefit most from interventions aimed at reducing craving through VR-CET.

Future Directions: How Virtual Reality Can Further Improve the Assessment and Treatment of Eating Disorders and Obesity

Transdisciplinary efforts for further elucidating the etiology of eating and weight disorders and improving the effectiveness of the available evidence-based interventions are imperative at this time. Recent studies indicate that computer-generated graphic environments-virtual reality (VR)-can integrate and extend existing treatments for eating and weight disorders (EWDs). Future possibilities for VR to improve actual approaches include its use for altering in real time the experience of the body (embodiment) and as a cue exposure tool for reducing food craving.

Telemental health: A status update

A rather large body of literature now exists on the use of telemental health services in the diagnosis and management of various psychiatric conditions. This review aims to provide an up-to-date assessment of telemental health, focusing on four main areas: computerized CBT (cCBT), Internet-based CBT (iCBT), virtual reality exposure therapy (VRET), and mobile therapy (mTherapy). Four scientific databases were searched and, where possible, larger, better-designed meta-analyses and controlled trials were highlighted. Taken together, published studies support an expanded role for telepsychiatry tools, with advantages that include increased care access, enhanced efficiency, reduced stigma associated with visiting mental health clinics, and the ability to bypass diagnosis-specific obstacles to treatment, such as when social anxiety prevents a patient from leaving the house. Of technology-mediated therapies, cCBT and iCBT possess the most efficacy evidence, with VRET and mTherapy representing promising but less researched options that have grown in parallel with virtual reality and mobile technology advances. Nonetheless, telepsychiatry remains challenging because of the need for specific computer skills, the difficulty in providing patients with a deep understanding or support, concerns about the "therapeutic alliance", privacy fears, and the well documented problem of patient attrition. Future studies should further test the efficacy, advantages and limitations of technology-enabled CBT, as well as explore the online delivery of other psychotherapeutic and psychopharmacological modalities.

The effect of repeated exposure to virtual gambling cues on the urge to gamble

INTRODUCTION

This study aimed to investigate the effectiveness of using a virtual reality (VR) casino environment in cue exposure therapy (CET) for gambling. The main objective of this study was to assess the ability of five VR casino cues to elicit subjective reactions and physiological responses that can be used within the CET paradigm. A second objective was to analyze changes in participants' urge to gamble after repeated exposure to a VR casino program and relaxation training.

METHODS

Twelve recreational gamblers were exposed to five virtual environments with casino-related cues that reproduced typical gambling situations. Self-reported subjective urges and psychophysiological responses were recorded during exposure.

RESULTS

All virtual environments with casino-related cues generated craving in recreational gamblers, whereas no increase in the psychophysiological variables was observed. In addition, urges to gamble elicited by VR casino environment reduced through repeated exposure and relaxation training.

CONCLUSION

These findings provide evidence of the effectiveness of VR for simulating casino environments in the treatment of gambling.

Effects of systematic cue exposure through virtual reality on cigarette craving

INTRODUCTION

Cigarette cravings have been associated with less successful attempts to quit smoking and a greater likelihood of relapse after smoking cessation. Background craving refers to a relatively steady and continuous experience of craving, while cue-induced craving refers to phases of intense craving triggered by cues associated with smoking. Cue exposure treatment (CET) involves repeated exposure to stimuli associated with substance use in order to reduce craving responses. However, mixed results have been found regarding the effect of CET on both types of craving. The aim of this study was to assess the effect of systematic virtual reality cue exposure treatment (VR-CET) on background and cue-induced cravings.

METHODS

Participants were 48 treatment-seeking smokers. The VR-CET consisted of prolonged exposure sessions to several interactive virtual environments. The VR-CET was applied once a week over 5 weeks. An individualized hierarchy of exposure was drawn up for each patient starting from the easiest virtual environment. Background and cue-induced cravings were recorded in each session.

RESULTS

Cue-induced craving decreased over each session as a result of prolonged exposure. VR-CET also reduced cue-induced and background cravings across the 5 sessions, showing a cumulative effect across the exposure sessions.

CONCLUSIONS

Our results evidenced the utility of VR-CET in reducing both types of cigarette craving. A combination of CET through VR with psychological treatments may improve current treatments for smoking cessation.

The use of virtual reality in craving assessment and cue-exposure therapy in substance use disorders

Craving is recognized as an important diagnosis criterion for substance use disorders (SUDs) and a predictive factor of relapse. Various methods to study craving exist; however, suppressing craving to successfully promote abstinence remains an unmet clinical need in SUDs. One reason is that social and environmental contexts recalling drug and alcohol consumption in the everyday life of patients suffering from SUDs often initiate craving and provoke relapse. Current behavioral therapies for SUDs use the cue-exposure approach to suppress salience of social and environmental contexts that may induce craving. They facilitate learning and cognitive reinforcement of new behavior and entrain craving suppression in the presence of cues related to drug and alcohol consumption. Unfortunately, craving often overweighs behavioral training especially in real social and environmental contexts with peer pressure encouraging the use of substance, such as parties and bars. In this perspective, virtual reality (VR) is gaining interest in the development of cue-reactivity paradigms and practices new skills in treatment. VR enhances ecological validity of traditional craving-induction measurement. In this review, we discuss results from (1) studies using VR and alternative virtual agents in the induction of craving and (2) studies combining cue-exposure therapy with VR in the promotion of abstinence from drugs and alcohol use. They used virtual environments, displaying alcohol and drugs to SUD patients. Moreover, some environments included avatars. Hence, some studies have focused on the social interactions that are associated with drug-seeking behaviors and peer pressure. Findings indicate that VR can successfully increase craving. Studies combining cue–exposure therapy with virtual environment, however, reported mitigated success so far.

Role of cues and contexts on drug-seeking behaviour

Environmental stimuli are powerful mediators of craving and relapse in substance-abuse disorders. This review examined how animal models have been used to investigate the cognitive mechanisms through which cues are able to affect drug-seeking behaviour. We address how animal models can describe the way drug-associated cues come to facilitate the development and persistence of drug taking, as well as how these cues are critical to the tendency to relapse that characterizes substance-abuse disorders. Drug-associated cues acquire properties of conditioned reinforcement, incentive motivation and discriminative control, which allow them to influence drug-seeking behaviour. Using these models, researchers have been able to investigate the pharmacology subserving the behavioural impact of environmental stimuli, some of which we highlight. Subsequently, we examine whether the impact of drug-associated stimuli can be attenuated via a process of extinction, and how this question is addressed in the laboratory. We discuss how preclinical research has been translated into behavioural therapies targeting substance abuse, as well as highlight potential developments to therapies that might produce more enduring changes in behaviour.

Portrayal of tobacco use in prime-time TV dramas: trends and associations with adult cigarette consumption--USA, 1955-2010

OBJECTIVE

Although portrayal of television (TV) and movie tobacco use has been linked with initiation of cigarette smoking in adolescents, its association with smoking in adults has not been assessed. Therefore, we examined long-term and annual changes in tobacco portrayal in popular US TV dramas and their associations with comparable trends in national adult cigarette consumption.

METHODS

Tobacco use in 1838 h of popular US TV dramas was coded from 1955-2010. The long-term trend and annual deviations from trend were studied in relation to comparable trends in adult per capita cigarette consumption using correlational and time-series methods that controlled for other potential predictors.

RESULTS

TV tobacco portrayal has trended downward since 1955 in line with the historical trend in cigarette consumption. Controlling for changes in cigarette prices and other factors, annual changes of one tobacco instance per episode hour across 2 years of programming were associated with annual change of 38.5 cigarettes per US adult. The decline in TV tobacco portrayal was associated with nearly half the effect of increases in cigarette prices over the study period.

CONCLUSIONS

The correlation between tobacco portrayal in TV dramas and adult cigarette consumption is consistent with well-established effects of exposure to tobacco cues that create craving for cigarettes in adult smokers. Although tobacco use in TV dramas along with movies has declined over time, portrayal of smoking on screen media should be a focus for future adult tobacco control research and policy.

Influence of point-of-sale tobacco displays and graphic health warning signs on adults: evidence from a virtual store experimental study

OBJECTIVES

We tested the impact of banning tobacco displays and posting graphic health warning signs at the point of sale (POS).

METHODS

We designed 3 variations of the tobacco product display (open, enclosed [not visible], enclosed with pro-tobacco ads) and 2 variations of the warning sign (present vs absent) with virtual store software. In December 2011 and January 2012, we randomized a national convenience sample of 1216 adult smokers and recent quitters to 1 of 6 store conditions and gave them a shopping task. We tested for the main effects of the enclosed display, the sign, and their interaction on urge to smoke and tobacco purchase attempts.

RESULTS

The enclosed display significantly lowered current smokers' (B = -7.05; 95% confidence interval [CI] = -13.20, -0.91; P < .05) and recent quitters' (Β = -6.00, 95% CI = -11.00, -1.00; P < .01) urge to smoke and current smokers' purchase attempts (adjusted odds ratio = 0.06; 95% CI = 0.03, 0.11; P < .01). The warning sign had no significant main effect on study outcomes or interaction with enclosed display.

CONCLUSIONS

These data show that POS tobacco displays influence purchase behavior. Banning them may reduce cues to smoke and unplanned tobacco purchases.

Comparison of the effectiveness of virtual cue exposure therapy and cognitive behavioral therapy for nicotine dependence

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.

An observational study of group waterpipe use in a natural environment

INTRODUCTION

To date research on tobacco smoking with a waterpipe (hookah, narghile, and shisha) has focused primarily on the individual user in a laboratory setting. Yet, waterpipe tobacco smoking is often a social practice that occurs in cafés, homes, and other natural settings. This observational study examined the behavior of waterpipe tobacco smokers and the social and contextual features of waterpipe use among groups in their natural environment.

METHODS

Trained observers visited urban waterpipe cafés on multiple occasions during an 8-month period. Observations of 241 individual users in naturally formed groups were made on smoking topography (puff frequency, duration, and interpuff interval [IPI]) and engagement in other activities (e.g., food and drink consumption, other tobacco use, and media viewing).

RESULTS

Most users were male in group sizes of 3-4 persons, on average, and each table had 1 waterpipe, on average. The predominant social features during observational periods were conversation and nonalcoholic drinking. Greater puff number was associated with smaller group sizes and more waterpipes per group, while longer IPIs were associated with larger group sizes and fewer waterpipes per group. Additionally, greater puff frequency was observed during media viewing and in the absence of other tobacco use.

CONCLUSIONS

Overall, the results suggest that waterpipe smoking behavior is affected by group size and by certain social activities. Discussion focuses on how these findings enhance our understanding of factors that may influence exposure to waterpipe tobacco smoke toxicants in naturalistic environments.

Effects of blockade of α4β2 and α7 nicotinic acetylcholine receptors on cue-induced reinstatement of nicotine-seeking behaviour in rats

Exposure to environmental stimuli conditioned to nicotine consumption critically contributes to the high relapse rates of tobacco smoking. Our previous work demonstrated that non-selective blockade of nicotinic acetylcholine receptors (nAChRs) reversed the cue-induced reinstatement of nicotine seeking, indicating a role for cholinergic neurotransmission in the mediation of the conditioned incentive properties of nicotine cues. The present study further examined the relative roles of the two major nAChR subtypes, α4β2 and α7, in the cue-induced reinstatement of nicotine seeking. Male Sprague-Dawley rats were trained to intravenously self-administer nicotine (0.03 mg/kg/infusion, free base) on a fixed-ratio 5 schedule of reinforcement. A nicotine-conditioned cue was established by associating a sensory stimulus with each nicotine infusion. After nicotine-maintained responding was extinguished by withholding the nicotine infusion and its paired cue, reinstatement test sessions were conducted with re-presentation of the cue but without the availability of nicotine. Thirty minutes before the tests, the rats were administered the α4β2-selective antagonist dihydro-β-erythroidine (DHβE) and α7-selective antagonist methyllycaconitine (MLA). Pretreatment with MLA, but not DHβE, significantly reduced the magnitude of the cue-induced reinstatement of responses on the active, previously nicotine-reinforced lever. In different sets of rats, MLA altered neither nicotine self-administration nor cue-induced reinstatement of food seeking. These results demonstrate that activation of α7 nAChRs participates in the mediation of the conditioned incentive properties of nicotine cues and suggest that α7 nAChRs may be a promising target for the development of medications for the prevention of cue-induced smoking relapse.

Smoking a virtual cigarette increases craving among smokers

Previous studies have shown the efficacy of virtual reality (VR) environments that reproduce smoking-related stimuli for increasing self-reported craving and psychophysiological reactivity in smokers. However, no study to date has attempted to simulate smoking behavior itself by means of VR technology. The aim of this study was to assess the effect of smoking a virtual cigarette on self-reported craving levels and heart rate (HR) in a sample of smokers. Participants were 45 smokers randomly assigned to three VR conditions built into a virtual pub: smoking a virtual cigarette, throwing virtual darts at a virtual dartboard or just being in the virtual pub. Results showed that smoking a virtual cigarette significantly increased self-reported craving and HR when compared to the other two conditions. These results reveal that simulation of smoking behavior in a VR environment functions as an efficacious proximal cue that can be used for triggering craving under the cue-exposure paradigm.

[Virtual reality in the treatment of mental disorders]

Virtual reality is a media allowing users to interact in real time with computerized virtual environments. The application of this immersive technology to cognitive behavioral therapies is increasingly exploited for the treatment of mental disorders. The present study is a review of literature spanning from 1992 to 2012. It depicts the utility of this new tool for assessment and therapy through the various clinical studies carried out on subjects exhibiting diverse mental disorders. Most of the studies conducted on tested subjects attest to the significant efficacy of the Virtual Reality Exposure Therapy (VRET) for the treatment of distinct mental disorders. Comparative studies of VRET with the treatment of reference (the in vivo exposure component of the cognitive behavioral therapy) document an equal efficacy of the two methods and in some cases a superior therapeutic effect in favor of the VRET. Even though clinical experiments set on a larger scale, extended follow-up and studies about factors influencing presence are needed, virtual reality exposure represents an efficacious, confidential, affordable, flexible, interactive therapeutic method which application will progressively widened in the field of mental health.

Perhaps More Consideration of Pavlovian-Operant Interaction May Improve the Clinical Efficacy of Behaviorally Based Drug Treatment Programs

Drug abuse remains costly. Drug-related cues can evoke cue-reactivity and craving, contributing to relapse. The Pavlovian extinction-based cue-exposure therapy (CET) has not been very successful in treating drug abuse. A functional operant analysis of complex rituals involved in CET is outlined and reinterpreted as an operant heterogeneous chain maintained by observing responses, conditioned reinforcers, and discriminative stimuli. It is further noted that operant functions are not predicated on Pavlovian processes but can be influenced by them in contributing to relapse; several empirical studies from the animal and human literature highlight this view. Cue-reactivity evoked by Pavlovian processes is conceptualized as an operant establishing/motivating operation. CET may be more effective in incorporating an operant-based approach that takes into account the complexity of Pavlovian-operant interaction. Extinction of the operant chain coupled with the shaping of alternative behaviors is proposed as an integrated therapy. It is proposed that operant-based drug abuse treatments (contingency management, voucher programs, and the therapeutic work environment) might consider incorporating cue-reactivity, as establishing/motivating operations, to increase long-term success-a hybrid approach based on Pavlovian-operant interaction.