|Year : 2021 | Volume
| Issue : 4 | Page : 684-691
Application of augmented and virtual reality in cigarette smoking cessation: A systematic review
S Canty Sandra, R Anusha, PD Madankumar
Department of Public Health Dentistry, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||16-Aug-2021|
|Date of Decision||22-Sep-2021|
|Date of Acceptance||13-Dec-2021|
|Date of Web Publication||29-Dec-2021|
Department of Public Health Dentistry, Ragas Dental College and Hospital, 2/102, East Coast Road, Uthandi, Chennai - 600 119, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The goal of this systematic review was to describe the use of augmented reality and virtual reality in cigarette smoking cessation and the adherence to smoking cessation among smokers. We searched several databases to identify suitable studies published between September 2011 and September 2021 for inclusion in this review. Suitable MeSH terms were used to devise a precise search strategy using PubMed, Google Scholar, Cochrane Library, and Turning Research into Practice database. The search yielded 304 articles, of which 5 were selected and 4 were considered for quality assessment. All four studies suggested that when the intervention was given through virtual reality, the adherence to smoking cessation was apparently high. Promoting cigarette cessation through conventional techniques could take a longer time for achieving commitment among those who wished to quit, while virtual reality created an interest to quit smoking. Arranging for augmented and virtual reality experiences for smokers through mobile applications and virtual reality headsets in the future could help improve smoking cessation and adherence compared to conventional pamphlets for health education.
Keywords: Augmented reality, cigarette smoking, smoking cessation, virtual reality
|How to cite this article:|
Sandra S C, Anusha R, Madankumar P D. Application of augmented and virtual reality in cigarette smoking cessation: A systematic review. Cancer Res Stat Treat 2021;4:684-91
|How to cite this URL:|
Sandra S C, Anusha R, Madankumar P D. Application of augmented and virtual reality in cigarette smoking cessation: A systematic review. Cancer Res Stat Treat [serial online] 2021 [cited 2022 Jan 21];4:684-91. Available from: https://www.crstonline.com/text.asp?2021/4/4/684/334179
| Introduction|| |
One of the biggest health problems worldwide is cigarette smoking. The global tobacco usage has decreased from 1.397 to 1.337 billion people from 2000 to 2018. However, the decline in the number of tobacco smokers in the past decade was only 1.7%. Various new technologies such as augmented and virtual reality have emerged in the modern era, and the exploration of new techniques has piqued people's interest. Augmented reality is a technology that uses a mobile phone to superimpose digital elements onto the real world. The advantage of augmented reality as a therapy is its ability to be used in the real world. Virtual reality is a communication platform that encourages self-development and learning among its users and allows them to be immersed in the virtually created environment. It is used as a virtual model of a patient's anatomy and helps the surgeon improve his/her surgical technique with the help of a three-dimensional (3D) view from different angles and position. Virtual reality has also been applied in the areas of cardiology and neurology.
Studies have demonstrated that the use of virtual reality can help improve quitting rates among smokers. Studies have shown that 3%–5% smokers remained abstinent during the 1st year of smoking cessation with the help of virtual reality. Long-term use of both augmented and virtual reality has also been shown to diminish cravings and smoking behavior. Since augmented and virtual reality are emerging sciences, the goal of this systematic review was to emphasize their use in cigarette smoking cessation and the smoker's willingness to quit smoking.
| Methods|| |
To find, assess, and summarize all relevant findings pertaining to the application of augmented and virtual reality in cigarette smoking cessation, a systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines. The International Prospective Register of Systematic Reviews was used to register the protocol for this systematic review (ID: CRD42021267052) (Supplementary protocol 1).
Population, intervention, control, and outcomes analysis
The following population, intervention, control, and outcomes were used for generating a search strategy:
- Population: Adults aged between 18 and 50 years who smoke cigarettes
- Intervention: Cigarette cessation interventions given through augmented and virtual reality in the form of smartphone applications, virtual reality laboratories, online virtual reality videos
- Comparison: Conventional cessation techniques such as nicotine replacement therapy, nicotine replacement products, 5 A's model for treating tobacco use, online counseling, or no intervention
- Outcome: Adherence to smoking cessation assigned during the treatment or the number of completed or attended treatment sessions among cigarette smokers.
Studies fulfilling the following criteria were included in the systematic review:
- Studies involving the application of augmented and virtual reality in cigarette cessation
- Various types of studies such as cohort, cross-sectional, usability (usability refers to the evaluation of the augmented reality application by testing it with cigarette users), and clinical trials
- Studies conducted among individuals aged 18 years and above
- Studies published in the time period from September 2011 to September 2021
- Studies published in the English language.
The following studies were excluded from the systematic review:
- Studies involving the application of augmented and virtual reality in alcohol dependency along with tobacco cessation
- Non-interventional studies, review articles, expert opinions, and discussion articles
- Publications without an abstract and those that were outside the scope of this review (did not fulfill the eligibility criteria).
Literature search was performed in PubMed, Turning Research Into Practice database, Cochrane Library, and Google Scholar to identify relevant articles published in the specified time period. The search terms included “Augmented reality,” “Virtual reality,” “Cigarette smoking,” and “Smoking cessation.” “Augmented reality,” “Virtual reality,” “Cigarette smoking,” and “Smoking cessation” were the MeSH terms included in PubMed. We also searched the bibliographies of the selected articles to ensure that no relevant articles were missed. To find relevant articles, we looked through the references of all the full-text articles. The search phrases used in various databases are shown in [Table 1].
Finally, the full-text versions of all the articles whose abstracts met the inclusion criteria were read. [Figure 1] shows the PRISMA flowchart.
|Figure 1: Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram|
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Data extraction from the five included articles was done using a data extraction form. It included the first author's name, year of publication of the article, aim of the study, objectives of the study, study design, intervention, results, outcome, and inferences. [Table 2] presents the data extracted from the studies included in this systematic review.
In the study on augmented reality, the questions were related to the development and usability of the mobile application, and hence, quality assessment according to the Joanna Briggs Institute (JBI) critical appraisal checklist was not performed. The remaining four randomized controlled trials were analyzed for methodological quality using the JBI scale (2017) containing 13 questions which should be answered using yes/no/unclear/not applicable. For yes, the score is 1, and for no/unclear/not applicable, the score is 0. A total score of 9 and more indicates that the study is of good quality, between 4 and 8 indicates fair quality, and below 4 is considered poor quality. The results of quality evaluation are summarized in [Table 3].
|Table 3: Quality assessment of the included studies according to the Joanna-Briggs Institute critical appraisal checklist (2017)|
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The Review Manager Software 5.4 ( Cochrane Revman - UK ) was used to identify the risk of bias in these studies. The risk of bias was categorized as low, unclear, or high. The results of bias risk assessment are shown in [Figure 2], and the risk of bias summary is presented in [Figure 3].
Results of literature search
At first, the search returned 304 articles. Finally, adopting the PRISMA guidelines, 5 articles were found to be eligible for inclusion in the systematic review [Figure 1]. Of these, 4 articles were assessed using the JBI scale and their final scores were 8 (Pericot-Valverde et al., 2014), 10 (Pericot-Valverde et al., 2019), 9 (Caponnetto et al.), and 9 (Goldenhersch et al.). Of these, 3 articles were rated as good quality, 1 was rated as fair quality, and none of the articles were of poor quality.
In the study conducted by Vinci et al. in 2020, the augmented reality images which contained images of smoking caused higher smoking urges than augmented reality images which contained neutral images such as pen and pencil. In the study by Pericot-Valverde et al. conducted in 2014, virtual reality reduced both background and cue-induced desire to smoke, among smokers. The number of cigarettes smoked every day (F (4, 36) = 41.144, P < 0.001) and the level of carbon monoxide in the expired air decreased significantly among smokers. However, in another study conducted by the same group in 2019, it was reported that virtual reality was not effective in cigarette smoking cessation. The authors concluded that cue exposure treatment did not improve the success of cognitive-behavioral treatment (CBT) for smoking cessation. Cue exposure treatment increased the chance of relapse in those who had successfully attained cessation. Cue exposure treatment also caused an increased risk of relapse among those who achieved abstinence. The point-prevalence abstinence at the end of treatment in the CBT group was 51.9% and in the CBT + cue exposure treatment group was 56%. In a study by Caponnetto et al., the authors concluded that virtual reality improved the motivation for smoking cessation. In a study by Goldenhersch et al., at 90 days, the treatment group showed a 33% abstinence rate; the authors concluded that the treatment group smoked fewer cigarettes than the control group, which showed an abstinence rate of 5%.
| Discussion|| |
Virtual reality plays an important role in cigarette smoking cessation and smokers' willingness to quit. One of the biggest obstacles to smoking cessation is cigarette craving, which translates into low cigarette smoking cessation rates and greater relapse rates (the relapse rate is a measure of the success of the intervention that treats cigarette smokers). Virtual reality has shown the potential to induce behavioral modifications, which can reduce cigarette craving and aid in smoking cessation.
Pericot-Valverde et al. conducted a study in which the smokers were exposed to a virtual reality cue exposure treatment. In this study, the background and cue-induced cravings decreased significantly among smokers, due to virtual reality cue exposure treatment. The steady and continuous craving experienced was defined as background craving, while the intense craving triggered by smoking cues was referred to as cue-induced craving. The virtual reality system consisted of a laptop, eyewear, standard mouse device, and head tracker with a 3D sensor so that the participants could change the orientation. Situations such as drinking in a pub, eating breakfast at home, having coffee or lunch at a restaurant, walking on a street, and watching movies late at night were among the cues exhibited. Cigarettes and ashtrays were used as smoking signals, and cravings were assessed using a visual analog scale ranging from 0 to 100. This helped prepare the participants at home, both mentally and emotionally, for when they faced real-life triggers. Results showed that the duration of exposure plays an important role. The length of the virtual reality session was between 8 and 20 min. Thus, when the duration of exposure increased, the cue-induced craving reduced among smokers. Apart from these, the authors also attributed the decline in craving to reduction in the intake of nicotine, which was seen as decreased number of cigarettes smoked per day.
CBT sessions included information about tobacco consumption, nicotine withdrawal syndromes, pledging of patients to quit smoking, physiological feedback, and training in alternative behaviors. Pericot-Valverde et al. in 2019 reported that when cue exposure treatment was combined with CBT, it resulted in a significant reduction in cue-induced desire. At different time periods, however, there were no differences in the retention or abstinence rates between CBT and CBT combined with cue exposure treatment (end-of-treatment, 1-, 6-, and 12-month follow-up). Over a 12-month follow-up period, the CBT + cue exposure treatment group had a higher rate of relapse than the CBT group. The inclusion of a cue exposure treatment protocol in a CBT program had no effect on smoking cessation rates. This study also showed that the CBT + cue exposure treatment groups had higher long-term (12-month) relapse rates than the CBT group. The participants reduced their nicotine intake gradually, which could have led to reduction in craving. Major reasons for smoking relapse as identified by the authors included lack of confidence to abstain and response to smoking cues. The study also suggested that depression and stress could play an important part in relapse and suggested that treating these conditions could improve quitting and relapse rates.
In 2019, Caponnetto et al. reported that other visual antismoking stimuli were more effective in encouraging people to cease smoking and suggested that motivation played an important role in smoking cessation as well as in avoiding relapse. Smoking cessation motivation is dependent on two factors: captology and change. Captology refers to the science that deals with the design, research, and analysis of interactive products created for the purpose of modifying the attitude and behavior of people. The transtheoretical model of behavioral change is an integrative theory of treatment that analyzes a person's readiness to adopt a new healthier behavior and offers solutions, or changes processes, to help them do so. Captology was established specifically to change people's attitudes and actions. It was done through the interaction of humans with computers. The main objective using the transtheoretical model to be observed in smokers is the change from the “precontemplation” stage (no intention of changing behavior in the near future) to one of “determination” (decision to change behavior). Virtual reality provided the mind the stimulus to change in a motivational system, which played a huge role in smoking cessation as well as in avoiding relapse.
Goldenhersch et al. compared two groups; the intervention group was given virtual reality mindful exposure therapy, whereas the control group was given the online version of the smoking cessation manual. They reported that compared to the control group, which received a smoking cessation guide (3/60, 5% abstinence), the intervention group had a markedly increased abstinence rate (14/60, 23% abstinence). In addition, at the 90-day follow-up, the intervention led to a 33% (20/60) abstinence rate, as well as high levels of adherence. It was based on the concept of mindfulness. This has already been used in mHealth (the medical and public health practice supported by mobile devices such as mobile phones, patient monitoring devices, personal digital assistants, and other wireless devices), giving awareness to attend to any sensation. It teaches individuals to pay attention and helps them not to react to smoking triggers. The MindCotine program combined Virtual Reality, mindfulness, CBT and coaching and involved a group of psychologists, actors, and physicians, It was relatively expensive, and took a longer period of time. Thus, a cost-effective program could benefit more smokers to quit smoking and have better adherence.
Machulska et al. in 2020 reported that virtual reality approaches have been successful in psychiatric disorders through cognitive behavioral intervention. It has been reported that depression plays a major role in smoking dependency. The virtual reality approaches have been used to treat all phobias, depression, and other psychological conditions such as anxiety and low self-esteem. Studies have shown that light smokers face fewer difficulties than heavy smokers with virtual reality interventions. The difficulties faced by smokers include nicotine withdrawal symptoms, emotional trigger, pattern trigger, social trigger, and genetic contribution. Thus, if a real-life risk situation is incorporated in virtual reality training, the gap between the virtual reality training in the laboratory and real-life behavior can be bridged. This, in turn, can increase training generalizability and efficacy. A more realistic virtual reality environment can help participants enjoy the experience and be happy, while motivating them to train in virtual environments. This can contribute to increased adherence.
Virtual reality could play a big role in the reduction of background craving, which in turn could reduce the relapse rates. When a virtual reality intervention is incorporated with mindfulness or given for a very long period of time, the relapse rates are comparatively lower.
The limitation of the studies conducted by Valverde et al. and Caponnetto et al was the small study population, which made it difficult to interpret the assumption that virtual reality enabled people to stop smoking. As there were no follow-ups beyond the regular sessions, it was impossible to assess the long-term impact of virtual reality-cue exposure treatment on desire levels., In the study conducted by Pericot-Valverde et al. in 2019, the authors did not report the reductions in craving beyond the virtual environments. However, Goldenhersch et al. in 2020 reported that virtual reality was not interactive and could not track cravings., In addition, the lack of an easy and accessible version of this virtual reality-based application open for every individual is a major hindrance to implementing the approach for smoking cessation.
In the study conducted by Vinci et al. in 2020, the augmented reality cue exposure was given in a real environment. The images were created with the help of a software blender. Seven participants reported that these images were more realistic than others. However, some participants reported that the stability of the image and the lighting were not satisfactory. Two of the participants reported that the colors were satisfactory. Among these, 10 smokers were asked about their urge to smoke. It was observed that the urge to smoke was high when the participants were exposed to augmented reality smoking cues. However, studies have not been conducted to assess quitting rates using augmented reality. An additional benefit of using augmented reality is that during the pandemic, the patients can expose themselves to these cues through mobile applications.
Of the five included studies, two reported conflicting results. Thus, further longitudinal investigations are required for tracing the effectiveness of augmented and virtual reality in cigarette smoking cessation.
| Conclusion|| |
Successful quitters must have a strategy in place to manage cravings and triggers. The earlier a smoker quits, the lower is his/her risk of developing cancer, pulmonary disease, and other smoking-related illnesses.
In 2021, the World Health Organization's theme for World No Tobacco day is “Commit to Quit.” In light of the current trend, we can use virtual reality as an intervention to quit smoking among light-to-moderate smokers who may benefit at a very early stage. Promoting cigarette cessation through conventional techniques may take a longer duration for achieving commitment among those who wish to quit, whereas virtual reality and augmented reality create an interest in smoking cessation.
Things get registered in our minds better when we experience them in reality. As public health practitioners and frontline workers, we have the responsibility to urge people to quit smoking. Arranging for augmented and virtual reality experiences for smokers through mobile applications and virtual reality headsets in future can help improve smoking cessation and adherence to it compared to conventional pamphlets for health education. Physicians can also provide online consultations and follow the patients up further to help them quit smoking.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]