Pubblicato: 2022-05-20

The virtual reality in smoking therapy

Medico specializzando, Clinica di Psichiatria, A.S.U. Friuli Centrale, Udine
S.O.C. Istituto di Farmacologia Clinica, Centro Servizi e Laboratori, A.S.U. Friuli Centrale; Farmacologia Clinica e Tossicologia, Dipartimento di Area Medica, Università degli Studi di Udine
virtual reality smoking cue exposure therapy cognitive behavioural therapy


Given the enormous social and health impact that cigarette smoking continues to have on the world population, identifying new therapies to combat smoking is an ever-present need. A possible solution to the problem comes from the technological world, thanks to which, it is possible to develop new synergies with the therapies currently in use. In particular, virtual reality is a recently developed technology that is well suited to be used also in the medical-health environment, especially in a complex sector such as behavioural and substance addictions. The possible applications of virtual reality in the specific context of smoking were then evaluated, focusing on the effectiveness of the methods used and possible developments in this area.

Introduction: virtual reality and cognitive behavioural therapy

Cigarette smoking exerts an important form of behavioural conditioning on the addict, responsible not only for the genesis and maintenance of craving, but also for relapses [1]. The most recent guidelines, in fact, also take into account the psychopathological aspects of smoking, using an increasingly integrated and multidisciplinary approach [2]. In particular, the association between nicotine replacement therapy (NRT) and cognitive behavioural therapy (TCC) seems to be the strategy with the best efficacy, despite being a method supported by little scientific evidence [3]. In fact, the effectiveness of the treatments currently used in smoking appears limited, especially as regards the period of abstinence, in fact; only 30% of the people treated remain abstinent over time, even with combined therapies [4]. The same guidelines, therefore, highlight the importance of implementing new smoking treatment strategies, in particular to try to prevent relapses [2].

A solution to this problem could come from technological progress and in particular from the recent development of virtual reality (VR). VR is an interactive environmental simulation developed by a computer, with the aim of creating an artificial setting detached from reality, but at the same time indistinguishable on a perceptual (immersion) and emotional (presence) level [5]. Precisely because of these characteristics, the contexts of application are many, especially in the field of psychiatric pathologies, including addictions [6]. Specifically, evidence demonstrates an increase in the efficacy of cognitive behavioural therapy when used in combination with VR [7,8].

The purpose of our review was to evaluate the available studies regarding the use of VR in smoking, focusing on its functioning and possible methods of use. The hope is to use the knowledge acquired to implement a safe and effective VR protocol, to be associated with current anti-smoking therapies.

Technical aspects

For its operation, a VR device requires hardware and software that mutually communicate with each other. The first guarantees the physical support necessary to reproduce the stimuli designed to create the simulation, the second determines the characteristics of these stimuli [9](Figure 1).

On a conceptual level, three elements determine an effective virtual reality experience, immersion, presence and interactivity [10-12]. Immersiveness is determined by the realism of the simulated setting and is a function of the quality of the stimuli processed by the hardware. Presence is a complex concept that identifies the individual existential experience induced by the setting. In other words, it is the subjective experience perceived emotionally and physically, a function of the place or environment in which you are, even if you are aware that this setting could be fictitious, like that generated by the VR [10]. The presence is a function of numerous factors, but mainly by the content of the simulation, therefore, a prerogative of software design. The third element (interactivity) allows interaction with the simulated environment through coherent stimulations between the virtual and real environment, in order to maintain a balance between immersion and presence. Understanding these aspects is necessary to determine which characteristics a VR experience must have to be effective, regardless of the application context.

A brief impact on the safety of these devices is due, given the delicate health context, in fact, it emerged that the adverse effects of VR are a function of numerous technological and individual factors [13]. The most frequent adverse effect is motion sickness, which if secondary to VR defined as “Cyber sickness” (CS). The classic symptoms are comparable to the classic motion sickness, which is nausea, headache and dizziness. The etiology of CS is also attributable to that of classical motion sickness: there is a discrepancy between the movement perceived by the vestibular and visual system, compared to the proprioceptive system, with the difference that in the virtual context, this occurs with the subject not in motion [14]. However, most of the studies that have analysed these aspects have found no particular problems and describe the technology of VR as well tolerated, even in the healthcare setting [15,16]. Surely, the reduction of side effects over time has occurred thanks to the recent spread of VR devices for the mass market, as manufacturers are required to comply with construction standards and high safety profiles in order to market their products [5,17].

The applications of virtual reality in smoking

Several studies have shown that exposure to conditioning virtual environments causes the onset of craving in the smoker. In addition, the amount of craving generated can be superimposed on neutral or traditional stimulations, such as photos or videos [18,19]. The researchers then exploited this possibility to implement a virtual reality exposure therapy, defined as VR-CET (Virtual Reality Cue Exposure Therapy). The study by Pericot-Valverde and coll. [20] showed, in fact, that following repeated exposure to craving-inducing environments (Figure 2), there was a progressive reduction in craving, a consensual reduction in the number of cigarettes smoked and in the exhaled carbon monoxide values [20]. This reduction in craving was concrete and verifiable even in real life, up to a week after the session [21]. 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. [23], it was found that the association between TCC and VR-CET was more effective than TCC alone, resulting in a reduction in the number of cigarettes smoked and the rate of quitting smoking. The use of VR-CET in association with TCC, however, gave unexpected results in the study by Pericot-Valverde and coll. [24], in which there was an increase in relapses 6 months after the interruption of treatment. This study showed that the ways in which VR and behavioural therapies are associated are relevant for the therapeutic effect. It appears, in fact, that due to the strong immersive capacity of virtual reality, craving can even increase if there is not an adequate TCC support, particularly, in conjunction with the genesis of craving itself [24]. In other words, the VR-CET must not be used passively with respect to TCC, but must be integrated with the same. The study by Bordink and coll. [25], shows that, in fact, a simultaneous administration of TCC and VR-CET (defined as VRST) reduces both the craving and the number of cigarettes smoked, even after 6 months from the end of the treatment. Furthermore, the study highlights how the additional association of VRST and nicotine replacement therapy (NRT) is more effective than NRT alone, in particular on the levels of self-efficacy (subjective confidence to resist craving).

Recently, the study by Zandonai e coll. [26] innovatively applies VR-CET to smoking-associated memory. This method is based on the concept that exposure to related smoking stimuli would induce a positive consolidation of memory related to smoking. Since emotional memory is fundamental for human behavioural adaptation, acting at this level would lead to a more effective extinction of craving. The procedure that exploits this mechanism is called post-retrieval extinction. Specifically, once the recall of smoking memories was induced through inducing craving virtual settings, a VR-CET session was applied. It emerged that applying VR-CET after the reactivation of memory towards smoking is more effective in reducing craving than standard desensitization procedures [26].

A further example of the versatility of use of VR is represented in the study by Girard and coll. [27], in which, he tried to develop a synergy between VR and TCC through a playful approach to virtual simulation (Figure 3). In detail, a video game was developed that had as its purpose the destruction of virtual cigarettes through a gamification process (the application of game elements to non-playful contexts). Destroying cigarettes in the virtual world was more effective in decreasing addiction than neutral simulation (destroying marbles); moreover, abstinence was greater after 6 months in respect of control [27].

Among the possible application methods, it is important to illustrate how VR can also be used as a tool to convey information for preventive purposes. For example, the study by Gao and coll. [28] evaluated the effectiveness of VR in conveying preventive messages in the school setting, through a craving-inducing simulation within which strategies were taught to counteract craving itself. It turned out that the students effectively learning the information transmitted, resulting more informed than before the VR session [28]. A more recent study by Borreli and coll. [29], in which the information session in VR was submitted during dental hygiene, highlights how this method is also effective in increasing the motivation in those who have no intention of quitting. Furthermore, the study underlines how the technology has performance and versatility that it can be used easily even in contexts that are not strictly specialized, such as a dentist’s office [29].

Virtual reality development model in smoking therapy

The literature has highlighted how VR can be used effectively in the therapy of smoking; however, there are no protocols or guidelines to follow for current use in clinical practice. The various studies, in fact, used application methods that are conceptually similar, but different from each other in terms of structural characteristics, hardware and software. For example, although we know that the association between TCC and VR is effective, the number or duration of the VR-CET sessions necessary to obtain the maximum effect is not known.

Further studies are therefore necessary to establish which are the parameters that can guarantee the best efficacy. To facilitate the design of such studies, it is useful to identify a reference model that allows the best use of the scientific evidence already available. Such protocol, should therefore be based on a virtual simulation that: uses devices that guarantee the best presence, immersion and interactivity; has a craving-inducing setting; is associated with an active TCC through an operator/user interaction in real time; teach adaptation strategies to combat craving in multiple social contexts (diversified environmental simulations); includes elements of gamification of information and TCC procedures.

In addition to the listed characteristics, it is possible to hypothesize further therapeutic elements to be associated with RV therapy. For example, given that one of the basic mechanisms of TCC is conditioning, it would be possible to introduce elements of positive and negative reinforcement to the therapeutic process, exploiting the emotional impact of virtual simulation. In particular, one of the fundamental forms of conditioning in the learning process is fear conditioning, or the association between a neutral stimulus and an unpleasant one, which over time induces avoidant behaviour towards the neutral stimulus [30]. Assuming that the behaviour to be avoided is the consumption of tobacco, inducing a fear conditioning towards the cigarette, would have a significant impact on reducing addiction. As proof of this possible mechanism, the studies by Reichenberger and coll. [31] and Shiban and coll. [32]have shown how VR is effective in inducing fear conditioning in the user, in particular in association with aversive haptic stimuli, such as electrical impulses or unpleasant sounds. Implementing a study that also integrates these aspects, could fifthly further increase the effectiveness of the therapies previously analysed.


From the literature it emerged that VR can be used effectively in the therapy and prevention of smoking. With regard to its operation, we have seen how this technology allows for high immersion, presence and interactivity and how researchers to increase the effectiveness of TCC, an essential component of current anti-smoking therapies, can exploit these elements. One of the mechanisms most used in the various studies is to induce craving in the smoker through repeated exposure to the simulated environment, that is, by implementing a progressive desensitization procedure through VR.

The element that differentiates the various studies, however, is how TCC is associated with the desensitization process and what other standard therapeutic strategy associated with it. In particular, it is not yet known precisely what the indispensable elements that guarantee the best effectiveness are. In any case, regardless of the method used, it was evident that an active and integrated approach to other validated forms of therapy is the solution with the best efficacy. The multidisciplinary approach, therefore, is reconfirmed as the winning way to combat smoking.

Furthermore, thanks to the high emotional impact generated by the simulations, VR can be used to convey anti-smoking information for preventive purposes. Not only that, given the recent evolution of VR devices, the context of use is varied and not exclusively medical-specialist.

In conclusion, further studies are needed to identify guidelines that establish the optimal use of VR in the context of addictions, especially with regard to the parameters of the simulation, such as duration, frequency and environmental contents. In order to favour this research process, a future diffusion of VR in the treatment of smoking, a basic protocol has been hypothesized that encompasses all the characteristics that emerged from the literature. The theoretical model resulting from the integration of acquired knowledge can therefore be summarized as an aversion therapy in VR, or a conditioning that induces the cessation of cigarette smoking through the use of elements of fear as reinforcement or punishment. Further studies are indicated to evaluate the effectiveness of this model.

Figures and tables

Figure 1.Schematic of a VR system: the software is processed by a computer to be sent to the viewer for audiovisual reproduction. The haptic systems allow you to interact with the virtual setting.

Figure 2.Example of craving/induced simulation.

Figure 3.Simulation where the patient tries to grab and destroy the virtual cigarette.


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Enrico Bonomo

Medico specializzando, Clinica di Psichiatria, A.S.U. Friuli Centrale, Udine

Massimo Baraldo

S.O.C. Istituto di Farmacologia Clinica, Centro Servizi e Laboratori, A.S.U. Friuli Centrale
Farmacologia Clinica e Tossicologia, Dipartimento di Area Medica, Università degli Studi di Udine


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