Psychology of Addictive Behaviors Copyright 2006 by the American Psychological Association

2006, Vol. 20, No. 4, 484 – 489 0893-164X/06/$12.00 DOI: 10.1037/0893-164X.20.4.484

Smoking Cues in a Virtual World Provoke Craving in Cigarette Smokers

Stephen B. Baumann Michael A. Sayette

Psychology Software Tools, Inc. University of Pittsburgh

Twenty smoking-deprived cigarette smokers participated in a study to test the ability of smoking cues
within a virtual world to provoke self-reported craving to smoke. Participants were exposed to 2
virtual-reality simulations displayed on a computer monitor: a control environment not containing any
intentional smoking stimuli and a cue-exposure environment containing smoking stimuli. At various
points, participants rated their urge to smoke on a scale of 0 –100. Results indicated that baseline urge
ratings were equivalent in both conditions, but the maximum increase in urge ratings was significantly
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

higher in the cue-exposure environment than in the control environment. This is comparable to what in
This document is copyrighted by the American Psychological Association or one of its allied publishers.

vivo studies have reported, but with the advantage of simulating more naturalistic and complex settings
in a controlled environment.

Keywords: cigarette smoking, virtual reality, cue reactivity, craving, subjective rating

Several recent studies have found drug craving to predict relapse
(see Sayette et al., 2000). Although some efforts to treat drug abuse
with cue-exposure interventions designed to reduce craving have
shown promise (e.g., Drummond & Glautier, 1994; Monti et al.,
1993), a recent meta-analysis of cue-exposure treatment studies
(Conklin & Tiffany, 2002) suggests that they are largely ineffec-
tive. These authors propose that studies should be better informed
by contemporary models of learning in which context plays a large
role in modulating the conditioning of stimuli. Use of an isolated
cigarette pack as a cue in a laboratory, for example, should be less
effective than use of the cigarette pack in the environment in which
it is most likely to be used by the smoker.
Currently there are several approaches to eliciting cigarette
craving in a lab (see Sayette et al., 2000). One of the most popular
laboratory cigarette craving manipulations is in vivo cue exposure,
during which participants view—and in some cases hold or
smell—the drug. Despite the ability of in vivo smoking-cue expo-
sure manipulations to elicit robust urges (Carter & Tiffany, 1999;
Wertz & Sayette, 2001), there have been criticisms of this ap-
proach concerning the limited number of stimulus dimensions that
can be manipulated in a single session, procedures that usually
permit just one presentation of smoking cues, and an inability to
manipulate mood or idiosyncratic stimuli easily (Tiffany, 1992).
Concerns with in vivo exposure procedures have led to imagery-
based manipulations to elicit drug urges (e.g., Drobes & Tiffany,
1997). This approach can introduce a broad array of stimulus
Stephen B. Baumann, Psychology Software Tools, Inc., Pittsburgh, PA;
Michael A. Sayette, Department of Psychology, University of Pittsburgh.
This work was supported by National Institute on Drug Abuse Grant
1R43DA015967 awarded to Stephen B. Baumann and Psychology Soft-
ware Tools for the development of VR software for studies and treatment
of smoking addiction. Michael A. Sayette is a paid consultant to Psychol-
ogy Software Tools on smoking addiction and cue reactivity.
Correspondence concerning this article should be addressed to Stephen
B. Baumann, Psychology Software Tools, Inc., Suite 200, 2050 Ardmore
Blvd., Pittsburgh, PA 15206. E-mail: steveb@pstnet.com
material and can permit multiple presentations of the smoking
images. Nevertheless, the effects produced by imagery scripts are
not always as robust as in vivo cue exposure (Niaura et al., 1998),
and it is difficult to know how well a participant complies with the
request to concentrate on the imagery for a prolonged period of
time. Many participants simply are not strong imagers. Efforts to
improve upon imagery scripts by using videotapes have similarly
not improved upon in vivo craving ratings (Shadel, Niaura, &
Abrams, 2001).
Virtual reality (VR) offers potential for studies of craving. By
immersing participants in multisensory, realistic-looking environ-
ments, it is possible to provide stimulus cues of the experimenter’s
choosing and timing to elicit from participants more controlled
reactions, which can then be manipulated. VR has made strides in
improving the treatment of anxiety and phobias (Wiederhold &
Wiederhold, 2005) and has been used to study a variety of basic
research questions, especially in the areas of health and education
(e.g., Baumann, 2005; Burdea & Coiffet, 2003; Rizzo & Kim,
2005; Wiederhold & Wiederhold, 2000). In the hands of experi-
enced therapists, similar manipulations might be used to develop
new treatment strategies in which the VR manipulation of drug
craving is combined with cognitive-behavioral therapy and desen-
sitization therapy. There is evidence that both assessment (Gwalt-
ney, Shiffman, & Sayette, 2005) and treatment (Monti et al., 1993;
Sayette, 2004) can be improved if therapists work with and ob-
serve their patients while the patients are experiencing craving.
Recently, VR has been used to elevate self-reported urges in
smokers (Bordnick et al., 2004) and has proven superior to static
pictures in inducing craving in smokers (Lee et al., 2003). Both
studies used head-mounted displays (HMDs), which are costly and
cumbersome. These studies also did not permit participants to
interact much with the virtual environment, thus limiting their
utility in simulating naturalistic settings and in exploring differen-
tial craving provoked by specific triggers. Moreover, neither study
tested smokers while they were deprived of nicotine. It is unclear
how well urges of nondeprived smokers resemble those of de-
prived smokers (see Sayette, Martin, Hull, Wertz, & Perrott,

484
 BRIEF REPORTS
2003). Because most lapses occur when smokers are deprived of
nicotine, and because cravings tend to remain low under nonde-
prived conditions, it is critical to evaluate VR methods using
nicotine-deprived smokers.
Consequently, we designed an experiment to test the ability of
interactive VR simulations displayed on a standard 21-in. com-
puter monitor with stereo speakers to provoke cravings in deprived
smokers. This is a less complicated and less expensive way of
presenting simulations that may make VR technology more ap-
pealing to a wider range of researchers and clinicians. We hypoth-
esized that this method, although perhaps not as immersive as VR
with HMDs, would still cause significant increases in craving.
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Method
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Participants
Twenty-two participants, who had smoked for at least two years, were
recruited through posted flyers, local newspaper ads, and word of mouth.
They were asked to abstain from smoking for at least 12 hours before
arriving for testing. Participants were informed that their carbon monoxide
levels would be checked to ensure abstinence. After signing a consent
form, they completed the Fagerstrom Test for Nicotine Dependence
(Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991) and a short ques-
tionnaire about their demographics and smoking history.
Smoking Cues
A focus group of five smokers, with the same demographics as the
eventual study group, met to discuss cues that triggered their urges. They
listed a number of common cues that were constructed using three-
dimensional (3-D) computer graphics and placed within an existing soft-
ware product described elsewhere (Baumann et al., 2003). Based on their
comments and reports in the literature (e.g., Maude-Griffin & Tiffany,
1996), brand-specific stimuli were created that included ads on billboards
or benches in a virtual city; packs of cigarettes on tables in an apartment
and in a restaurant; ashtrays with cigarette butts in the apartment, in the
restaurant, and on the city street; smoking characters at locations on the city
street and in a restaurant; cigarettes for sale by the pack or carton; and a bar
scene with alcoholic beverages, smokers, and a sports program on TV. The
visual display in these environments was accompanied by relevant stereo
sounds, such as a character asking the subject if he or she had a spare
cigarette, traffic noise on the city streets, background music playing in the
restaurant, and play-by-play narration from a sportscaster for the hockey
game on the TV in the bar. The combination of visual and auditory stimuli
makes the scenes more realistic and immersive for participants. Five major
brands of cigarettes were available to choose from in a menu used by the
experimenter to configure the simulation without the participant’s knowl-
edge, and this set the ads and cigarette packs in the simulation for a specific
brand preferred by the participant.
Testing
All testing was performed using a 21-in. color computer monitor with
stereo speakers. A three-stage procedure was used to test the participants in
the VR simulation. First, in a pretest run participants practiced using the
joystick and mouse controls in a virtual environment not used in the testing.
The joystick was used for navigating around the virtual environments, and
the mouse was used to change viewpoint and to control objects, such as
opening and closing doors or turning on light switches, by clicking on
them. This practice time allowed participants who experienced nausea or
vertigo (i.e., cybersickness) to be excluded before data were collected, and
485
it allowed participants time to feel comfortable navigating through the
simulation without concerns of performance anxiety related to data
acquisition.
Second, participants were placed in a VR simulation without any inten-
tional smoking stimuli (control run). They were asked to explore a se-
quence of environments with occasional directions from the experimenter
to go to a certain area or to look at certain objects or characters. The route
always began in an apartment, then took a course out of the apartment
building to an urban main street, down both sides of the street, past fruit
and newspaper vendors, and finally into a restaurant. These areas were
included because smoking stimuli could be placed in them for the next run.
Participants also were allowed ample time to explore other areas along the
way.
Third, participants completed a smoking-cue run, in which various
smoking stimuli were embedded in the simulation at key locations that
participants would likely encounter during their tour along the same route
as in the control run. These stimuli included open cigarette packs, lighters,
ashtrays, and a cup of coffee in the apartment; vending machines in lobbies
in the apartment building and the restaurant; male and female smokers in
pairs or individually on the street with smoke coming from the tips of their
cigarettes; cigarette cartons for sale by two vendors on the city street; ads
on two large billboards and on the backs of many benches along the main
street; a food bar in the restaurant; and a smoking section and alcohol bar
in the restaurant featuring several smokers, some of whom were watching
a hockey game on television, with opened packs of cigarettes, lighters,
ashtrays, and opened beer bottles near several of the smokers.
By allowing an investigator to place selected stimuli in an area where a
participant has previously been in an earlier simulation, this framework
isolates the effects of each stimulus of interest from any extraneous
background stimuli that may be inadvertent triggers. The appearance of
smoking cues, in what was previously a rather neutral environment, sur-
prises many participants, who tend to spend extra time investigating the
particular trigger stimuli. For instance, they might see cigarettes for sale at
a newsstand that were not present in the initial environment (see Figure 1,
left). While they had spent little time investigating the newsstand in the
first run, they now stop and try to interact with the vendor by looking
closely and clicking on him with the mouse button in an attempt to
purchase cigarettes (see Figure 1, right).
Each run through the virtual environment took about 15 minutes. Par-
ticipants were asked to rate their urge to smoke at the beginning of each
run, whenever they encountered an overt smoking stimulus, when they
made a transition to a new area, and at the end of each run, for a total of
approximately 12 times during each run. They rated their urge to smoke
using a rating scale ranging from 0 (absolutely no urge) to 100 (the
strongest urge I have ever experienced) (Juliano & Brandon, 1998; Sayette
et al., 2003). The pictures in Figure 2 show the rating scale superimposed
on displays used in the control (left panel) and smoking-cue (right panel)
runs.
As in prior research, presentation of smoking cues followed the presen-
tation of neutral cues (e.g., Sayette et al., 2003; Sayette, Martin, Wertz,
Perrott, & Peters, 2005). Previous studies indicate that, when smokers are
nicotine deprived and exposed to smoking cues, their urges tend to remain
high if they are not permitted to smoke. Such carryover effects make it hard
to subsequently execute control-cue exposure. Studies that have elicited a
strong urge during smoking-cue exposure and have counterbalanced cues
often have not reported tests for order effects. Those that have provided
such data seem to observe order effects of the sort noted above (e.g.,
Hutchison, Niaura, & Swift, 1999; Rickard-Figueroa & Zeichner, 1985).
A debriefing was performed with each participant after the smoking run
to obtain information about the various triggers to smoke in his or her life,
feedback about the stimuli used in the simulations, and ways to improve
future simulations to evoke stronger cravings. Participants were asked to
rank order (1– 6) the strength of overt stimuli in the smoking run (the
 486 BRIEF REPORTS
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Figure 1. Newspaper vendor on urban street without cigarettes for sale in the control run (left) and with
cigarettes for sale in the cue-exposure run (right).
restaurant bar scene, smoking characters on the urban street, vending
machines, cigarette packs or cartons, advertisements, and ashtrays) that
were used to provoke craving to smoke.
Results
Of the 22 participants recruited, 20 (10 males, 10 females)
completed the testing. One participant was unable to complete
testing because of cybersickness, and some data for another par-
ticipant was corrupted and could not be analyzed. Data summa-
rizing the participant characteristics are reported in Table 1.
Due to a minimum of 12 hours of smoking abstinence, partic-
ipants began each run with similar craving ratings of about 50.
(Urge rating data are summarized in Table 2). An overall change
in urge score between runs was computed for each participant:
[(maximum urge rating during run with smoking stimuli minus
beginning urge rating during run with smoking stimuli) minus
(maximum urge rating during run without smoking stimuli minus
beginning urge rating during run without smoking stimuli)].1 Re-
sults indicate that the run with the embedded smoking stimuli
increased the urge to smoke by 15.1 points (SD ⫽ 22.1) more than
did the control run without smoking stimuli, a statistically signif-
icant increase [t (19) ⫽ 3.05, p ⬍ .01 (two-tailed)].2
Because of the preliminary nature of this VR smoking-cue
study, we report additional descriptive details about the data. There
was a 12.4-point increase in urge during the first run without any
intentional embedded smoking stimuli. Eleven participants (55%)
showed an increase of at least 10 points during this control run, and
in the debriefing session many mentioned that there were numer-
ous unintentional and idiosyncratic cues that triggered their urges.
Rank ordering of stimuli in the smoking run revealed that, on
average, the strongest stimuli in the simulation were the bar scene
(M ⫽ 1.68, SD ⫽ 1.06), followed by smoking characters on the
urban street (M ⫽ 2.68, SD ⫽ 1.16), cigarette packs or cartons
(M ⫽ 2.78, SD ⫽ 1.26), vending machines (M ⫽ 4.66, SD ⫽ 0.91),
ashtrays (M ⫽ 5.03, SD ⫽ 1.42), and advertisements (M ⫽ 5.17,
SD ⫽ 1.50). Twelve of the 20 participants ranked the bar scene as
the strongest trigger, and only two ranked it lower than second.
Although smoking characters on the urban street were ranked as
the second strongest trigger, reaction to them was highly variable,
with men generally reacting more strongly to male characters and
women reacting more strongly to female characters. In fact, sev-
eral female participants commented that the male characters were
“too dark,” “intimidating,” or “not inviting.” Location seemed to
have a strong effect on the reaction to cigarette packs or cartons,
with many participants expressing strong reactions to the cigarette
pack and lighter by a cup of coffee on the apartment dining-room
table and others to the cartons of cigarettes for sale at the news-
stand. This selective reactivity depended upon their individual
associations, such as where they had their first cigarette in the
morning or where they bought their cigarettes. Vending machines
were ranked no higher than third, and for many participants they
had a neutral (“don’t use”) or negative connotation because of the
high cost of cigarettes sold in the machines. Brand-specific ads
were ranked above ashtrays with cigarette butts, and seven partic-
ipants had a strong negative reaction to dirty ashtrays, labeling
them “disgusting” or a “turnoff,” because ashtrays reminded them
of how dirty their smoking habit could be.
Discussion
This study demonstrates that VR simulations containing rele-
vant smoking cues can manipulate craving in addicted smokers,
even when using a computer monitor instead of a more expensive
HMD. The effect is robust (77% of urge-scale maximum) and
compares favorably with many past studies of smoking-cue reac-
tivity (see Wertz & Sayette, 2001). Further, it reveals that simu-
1
Similar findings appear when baseline levels are ignored and the values
during smoking cue and control cue are directly contrasted (i.e., maximum
craving rating during run with smoking stimuli minus maximum craving
rating during run without smoking stimuli).
2
Since participants were self-selected, as in most cue-reactivity studies
that recruit volunteers, it might be argued that the assumption of random
sample selection for the t test was violated. Consequently, a nonparametric
Wilcoxon matched-pairs test was performed, and the result was the same
with p ⬍ .01.
 BRIEF REPORTS
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Figure 2. Analog rating scale superimposed on apartment scene (left) and restaurant bar scene (right). The urge
rating in the apartment at the beginning of the simulation was 54, and later in the restaurant with embedded
smoking stimuli it was 89.
lations can be personalized to a great extent, such as by offering
specific brands, objects, and scenes that are strongly related to an
individual’s smoking habit.
As noted above, there are important differences between the
present study and the previous controlled VR study of smoking
craving by Bordnick et al. (2004). Only 13 participants were tested
in that study, primarily females (9), while we tested 20 subjects
balanced for gender. Participants in the study by Bordnick et al.
were able to smoke a cigarette before their test session. In contrast,
all participants in this study were nicotine-deprived for at least 12
hours, and their urge to smoke reached the upper end of the scale.
In the Bordnick et al. study, participants wore an HMD, while in
the present study participants viewed the simulation on a 21-in.
monitor. This may be less immersive, but it makes the technology
far more affordable and less cumbersome to use. In addition, the
VR environments in Bordnick et al. were two-dimensional and
simply required participants to watch movies of real actors who
were overlaid upon computer-generated backgrounds. In contrast,
our study used full 3-D simulations that allowed participants to
navigate freely around the environments and interact with objects
and characters as in a computer game. This approach provides
opportunities for exploration and feedback between the participant
and clinician about idiosyncratic stimuli that are perceived as
triggers for smoking craving. Finally, cigarette packs, cartons, and
advertisements were chosen from five specific brands, so it was
possible to match the participant’s first or second favorite brand in
nearly all cases.
Table 1
Participant Characteristics
Variable M (SD)
Age 37.7 (12.3)
CO reading 5.3 (3.4)
Years smoking 19.1 (12.2)
Packs per day 1.0 (0.4)
Fagerstrom Score (0–10) 4.4 (3.0)
487
Definitions of VR vary, and many people associate it with the
use of hardware such as HMDs and special interactive sensing
gloves. However, much VR research done today and presented at
international conferences involves the use of standard computer
monitors or larger projection screens. A more comprehensive
definition of VR has been offered by Burdea and Coiffet (2003) as
“a high-end user– computer interface that involves real-time sim-
ulation and interactions through multiple sensorial channels” (p.
3). The technology used in this study conforms to that definition
across a spectrum of possible VR techniques that run the gamut
from computer games played on PCs to totally immersive rooms
(CAVEs) in which each surface is a projection screen, and the
user’s head movement is tracked to change the viewpoint (Stan-
ney, 2002).
Addictions research that uses VR technology is in its infancy.
Although the present study found a potent effect of a virtual
environment embedded with smoking cues, there are some limi-
tations to this work that can be addressed in future studies. First,
research is needed to enhance the degree to which smoking cues in
the virtual environment generalize to real world situations. As is
true with nearly all cue-exposure research (see Wertz & Sayette,
2001), our research focused on deprived smokers not currently
interested in quitting. Clearly it is important to conduct smoking
studies using smokers who are seeking treatment, since such
individuals might respond differently to cues than the self-selected
sample of continuing smokers in this study (see Wilson, Sayette, &
Fiez, 2004). In addition, larger studies are needed to further sup-
port the utility of VR methods in smoking research. Nonetheless,
despite reporting data from only 20 participants in this preliminary
Table 2
Mean (SD) Urge Ratings
Viewing condition Beginning of run Maximum
Without smoking stimuli 49.7 (25.5) 62.1 (27.0)
With smoking stimuli 49.8 (28.6) 77.3 (25.4)
 488 BRIEF REPORTS
study, the statistically significant effect of our smoking environ-
ments permits some confidence in interpreting the findings.
Second, despite the robust increase in urge between the smoking
and control environments, the effect might have been stronger had
there not been inadvertent smoking cues in the control run. Par-
ticipant debriefings revealed that in some cases seemingly benign
cues appearing during the control run inadvertently elicited urges.
For instance, simply exiting a public building is a trigger to smoke
because it is often the first opportunity to smoke after confinement
in nonsmoking areas. These associations are reminiscent of place-
preference conditioning in animal studies (Bardo & Bevins, 2000).
In fact, some participants were emphatic that the strength of a
stimulus, such as a pack of cigarettes, was highly dependent upon
its location in the apartment and varied greatly when on the
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bedside table or on the table by the TV, depending upon personal
smoking habits and location preferences.
Third, future research might consider using a between-
participant design in which only control or smoking cues are
provided to participants. (That was not done in this study, in
part, because a subset of the strongest-reacting participants was
selected for a separate functional MRI study performed weeks
later, which required data collection during both cue runs.) This
would rule out the possibility that the increase in urge during
smoking cues was due simply to an order effect or the passing
of time. We believe, however, that the findings argue strongly
against such an interpretation for two reasons: (1) Following the
control run, urges actually dropped back down to the levels they
were at prior to the run. That is, urges were not steadily rising
across the study irrespective of the type of run. (2) Even during
the smoking-cue run, urges changed according to the cues in the
environment at that moment.
Fourth, research is needed that offers a more diverse group of
craving measures. To date, VR studies of cue-elicited craving have
relied on urge ratings, but physiological measures such as skin
conductance, heart rate, and functional MRI can be used, and such
studies are in progress.
One aim of VR is to approximate daily life and to reveal
smoking triggers as smokers move through simulated environ-
ments. Even the best VR methods, however, cannot replicate
actual life experiences with real-world consequences. In addi-
tion, VR cannot account for all relevant contexts for a particular
individual. Still, the technology holds promise for advancing
cue-exposure research and treatment beyond current in vivo and
imaginal approaches. By using VR techniques to elicit cravings
in the clinic, a therapist can assess patients while they are
vulnerable to relapse. As noted elsewhere, it is not smokers’
typical attitudes about their smoking, but their attitudes while
craving (i.e., their “Achilles’ heel”) that might be most predic-
tive of relapse (Gwaltney et al., 2001, 2005). Similarly, VR
techniques may provide a flexible and feasible method for
therapists to help patients overcome their urges. The vast ma-
jority of smokers who successfully quit but then relapse report
using none of the coping skills they had mastered in treatment
during their moment of crisis (Brandon, Tiffany, Obremski, &
Baker, 1990). By making it easier for clinicians to employ
craving induction techniques, VR may lead to treatment ad-
vances. Behavior therapists could use VR techniques to help
smokers extinguish conditioned responses to drug cues. Alter-
natively, cognitive therapists might use VR-generated craving-
induction techniques to help patients manage their urges effec-
tively and enhance self-efficacy so that they will maintain
abstinence in future high-risk situations. Regardless of one’s
clinical orientation, the current study provides preliminary ev-
idence that VR ultimately may address some of the limitations
of existing cue-exposure approaches (Conklin & Tiffany,
2002).
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Received March 17, 2005
Revision received November 10, 2005
Accepted November 28, 2005 䡲