Preventing Teen Smoking With Virtual Reality

Kenneth Nemire, Ph.D.
Joshua Beil, B.A.
Interface Technologies Corporation

Ronald W. Swan, Ph.D.
Human Development Associates

Running title: Preventing teen smoking with virtual reality

Direct correspondence to:

Kenneth Nemire
Interface Technologies Corporation
1840 - 41st Ave., Ste. 102, Capitola, CA 95010 USA
831-688-3084 (tel), 831-688-3084 (fax), knemire@appliedve.com.

Abstract

Smoking incidence is rising among adolescents but not adults. While many prevention programs are effective, there is room for improvement. This pilot project combined the well-documented benefits of Life Skills Training (LST) with the unique multisensory, 3D qualities of virtual environment (VE) technology to address some of the disadvantages of traditional prevention programs. In an eight-week pilot study, 72 seventh-grade students were randomly assigned to either LST, VE, or non-intervention control groups. The VE system included goggles, synthesized speech, spatial trackers on head and hand, hand-held controller, and speech recognition system. Questionnaires measured participants’ smoking knowledge, attitudes and behavior. A bogus pipeline procedure was used to increase reliability of the self-report measures. Pre-exposure data showed no significant differences between groups on the questionnaire. Post-exposure data indicated improvements in attitudes in the LST and VR groups. In addition, the VR group showed more accurate information concerning peer and adult cigarette use, and more likelihood of using coping and refusal skills. Usability and acceptability questionnaire data showed ease of use and learning, and that participants would use VE technology frequently if it were available to them at school. These data indicated that this VE application is a promising tool for keeping teens healthy.

Introduction

The societal costs of smoking tobacco are tremendous. Smokers are three times more likely to die of cancer than non-smokers. Since the 1950's, lung cancer has increased more than 400% in women; more than 80% of cancer deaths are linked to cigarettes; and, smoking contributes to the contraction of a variety of other cancers, as well as to heart disease and high blood pressure. The nation's annual medical bill from tobacco-related illness is $50 billion7. When other costs are included, such as time lost from work, the U.S. Congress Office of Technology Assessment estimates that smoking costs more than $140 billion every year (more than $4,400 a second).

Unfortunately, smoking is on the rise among adolescents.9,16 Although further research of smoking prevention and cessation in adolescents is needed, little progress has been made;26 additional efforts to prevent teenage smoking are needed. While many prevention programs are effective, there are some drawbacks to their use. Prevention programs are accessible only at certain times and for brief periods, and require periodic booster sessions to prevent smoking incidence. Combining the beneficial aspects of smoking prevention programs with the unique multisensory, 3D qualities of virtual environment (VE) technology, may address some of the disadvantages of traditional prevention programs. First, VE technology can be particularly engaging and acceptable for teens since the computer-generated sights and sounds are similar to popular video games. Second, VE technology may present information and skill building exercises, such as refusal skills, more persuasively than is possible with text and videotapes. Third, the VE program could be continuously available for student use in schools' computer labs and provide sources for booster sessions.

Virtual environment technology.

Immersive virtual environments (IVEs) have properties that make them uniquely suited for supporting cognitive-behavioral interventions and educational processes. A virtual environment (VE) is defined as an application that allows persons to navigate and interact in real time with a computer-generated world. An immersive VE (IVE) is distinguished by presenting the individual a multisensory, 3D computer-generated world that surrounds the person. In putting on an accompanying headset and starting the IVE program, the viewer is fully immersed--or surrounded--by the computer-generated "world"; by turning one's head the viewer sees a new view or angle of the scene. The effect simulates the way a person sees, hears and interacts in the physical world. Although the most common form of VEs can be found in video games, more and more software is being developed for training, educational, and other needs.

Life Skills Training (LST).

LST is a cognitive-behavioral prevention program that has been shown to be effective up to six years after the original intervention.2,3,4 The main purpose of the LST approach is to facilitate the development of generic life/coping skills as well as skills and knowledge more specifically related to resisting social influences to use tobacco products and other drugs.

There are three major LST components.5 The Substance-Specific Component contains material describing the short- and long-term consequences of substance abuse; information about prevalence rates among both adults and adolescents in order to correct normative expectations; information and class exercises demonstrating the immediate physiological effects of cigarette smoking using biofeedback apparatus; material concerning media pressures to smoke or drink; and techniques for resisting peer pressure to smoke, drink, or take drugs. The Personal Skills Component contains material designed to foster development of critical thinking and responsible decision-making, provide students with techniques for coping with anxiety, and provide students with the basic principles of personal behavior change and self-improvement. The Social Skills Component contains material designed to improve general interpersonal skills such as effective communications, and verbal and non-verbal assertive skills. These skills are taught using a combination of instruction, modeling, rehearsal, feedback, reinforcement, and extended practice through homework assignments. Teaching these skills has been effective in preventing substance abuse, as well as enhancing general and specific coping abilities in non-abusing populations.

Integrating LST with VE technology.

Virtual reality may prove to be exceptionally attractive and accepted by the adolescent age group and thus more effective than other instructional media11. There are a number of ways in which immersive VE technology may be useful in augmenting the effectiveness of LST. These are based on issues known to influence the effectiveness of prevention programs.5,12

While the magnitude of the effects of prevention programs range from 50 to 80% reduction in the incidence of substance use behavior, there are few data on the critical components that make programs effective.5 Other delivery technologies, like immersive VE technology, may enhance effectiveness.

The three-dimensional images and interactivity possible with immersive VE technology may enable the presentation of information and skill-building exercises (e.g., refusal skills), more persuasively than is possible with videotapes and other modes of presentation.

The multisensory nature of immersive VE technology may allow more compelling presentations of educational material such as showing the immediate negative consequences of smoking.

The immersive option of VE technology may eliminate social and environmental distractions and result in greater individual focus, concentration, integration of experience and transfer of learning.

The computer-based nature of VE technology makes it relatively easy to modify training scenarios to allow teens to practice general and specific skills in a variety of situations.

VE technology also makes it easy to modify the characters and information in the virtual world. This may be useful for presenting, for example, multiple credible "heroes" to adolescent populations of different gender and ethnicity.

VE technology may be more compelling and acceptable to adolescents. The computer-generated sights and sounds that surround the person are similar to popular video and arcade games. In general, teens understand and accept the technology and are more likely to use it, thus providing greater opportunities for learning and practicing LST skills.

Virtual worlds are engaging. People who are introduced to this technology want to use and re-use the programs often because virtual worlds provide both a sense of excitement and a very personal and private space due to the enclosing head-mounted display. The features can be programmed so they are different with each use. As a result, people are more likely to enjoy and use a tool that provides a multisensory experience that surrounds them and reacts to their movements than they are to sit passively and listen to an audiotape or watch a video.

This pilot project integrated VE technology with educational and skill-building material from Life Skills Training (LST). Material from all three LST components were provided in the virtual learning environment: Substance-Specific (short- and long-term consequences of substance abuse, information about prevalence rates, and techniques for resisting peer pressure); Personal Skills (techniques for coping with anxiety); and Social Skills (verbal and non-verbal assertive skills taught using a combination of instruction, rehearsal, feedback, and reinforcement). The virtual learning environment was designed as an adjunct to the LST program, providing another media for presenting information and allowing students to practice cognitive-behavioral skills. The dynamic combination of cognitive-behavioral approaches and virtual sights and sounds promises to introduce and reinforce powerful tools for helping individuals learn the life skills necessary to avoid using tobacco products and to avoid engaging in other detrimental behaviors.

Because of space limitations, this paper primarily presents evaluations of using the VLE for presenting information from the Substance-Specific and Personal Skills Components; evaluations on using the VLE data for acquisition of assertiveness skills will be presented in a later paper. Consequently, this paper presents data from a pilot study designed to evaluate whether prevention education material presented with a virtual reality medium resulted in enhanced learning when compared with using traditional methods found in prevention education groups; Further, it is expected that the virtual learning environment will be fun and uniquely attractive, which would help motivate students to use the virtual learning environment tool. This would be a very positive outcome, leading, perhaps to a powerful resource for those who are unable to resist pressures to smoke on their own.

Method

Participants

Seventh grade students were recruited from a local middle school and screened to obtain the following characteristics: no alcohol or other drug ingestion for 72 hours prior; no psychiatric morbidity; no psychotropic medications; no history of seizure disorders or known intracranial pathology; no susceptibility to motion sickness; normal or corrected-to-normal vision and hearing; English readers to ensure understanding of the questionnaire. Study participants were treated in accordance with APA guidelines. Initially, seventy-two seventh-grade students were randomly assigned to one of three conditions: LST group session, VE program, and non-intervention control. Attrition due to scheduling and transportation issues over the eight-week period resulted in 15 students per group. Of these students, 44 were Latino. Gender was about equally represented in the three groups.

Apparatus and Materials

The LST program included a workbook and relaxation tape,1 group discussion, and role-playing activities related to self-esteem, decision-making, dangers of smoking, anxiety coping skills, and assertiveness skills.

The VE system included goggles (Virtual I/O), synthesized speech, electromagnetic spatial trackers on head and hand, hand-held controller, and a simulated speech recognition system. The VE program provided information on the dangers of smoking, anxiety coping skills, and opportunities for practicing assertiveness skills with virtual characters; additional information was provided with a workbook and relaxation tape1 and discussion.

Questionnaires were used to measure participants’ smoking knowledge and behavior, perception of the smoking prevention programs, and simulator sickness.

Smoking Knowledge And Behavior Questionnaire. This questionnaire consisted of 60 questions that covered the following categories: (1) use of cigarettes and other drugs, (2) intention to use cigarettes and other drugs, (3) perceptions of use among peers, (4) perceptions of use among adults, (5) attitudes towards smoking, (6) probability of refusal, (7) probability of using specific types of refusal skills, (8) autonomy in decision making, and (9) probability of using techniques to reduce anxiety.5 Prior to data analyses, all items were re-stated as positive statements to facilitate analysis and interpretation.

Usability Questionnaire. Likert scales were developed to investigate issues related to: (1) overall effectiveness of the test and instructions, (2) aesthetics; e.g., appeal of what participants saw, heard and felt, (3) usability of virtual displays; e.g., comfort, ease of use and perceptibility of visual and auditory displays, (4) usability of virtual controls, e.g., comfort and ease of using the speech and manual input devices, (5) immersion; i.e., feeling or sense of being in another world. Prior to data analyses, all items were re-stated as positive statements to facilitate analysis and interpretation.

Acceptability Questionnaire. This questionnaire, given as part of the usability questionnaire, probed issues such as whether students would want to use the VR program at school, where they would want to use it, and how often they would want to use it. Questions also sought more in-depth information about specific features that may make the VR program more or less fun and educational.

Simulator Sickness Questionnaire (SSQ). The SSQ has been validated as a tool to evaluate the severity of motion sickness symptoms associated with using vehicle simulators,18 and was administered to members of the VR group. The SSQ consisted of 16 items describing possible symptoms of simulator sickness: general discomfort, fatigue, headache, eyestrain, difficulty focusing, increased salivation, sweating, nausea, difficulty concentrating, fullness of head, blurred vision, dizzy eyes open, dizzy eyes closed, vertigo, stomach awareness, and burping. The sixteen symptoms can be rated on a four-point scale, with 0 indicating no symptoms and 3 indicating serious symptoms.

Saliva tests. Saliva samples on cotton swabs were taken as part of the bogus pipeline procedure (see Procedure, Day 1).

Procedure

Advertise/Recruit/Screen/Assignment. Seventh grade students were recruited from a local middle school. All respondees were screened so only those meeting study criteria were included. Participants were randomly assigned to one of three experimental or control groups.

Informed consent/Baseline (Day 1). Each group met at a different time so procedures specific to their group could be provided without biasing the other groups. The principal investigator provided a complete description of the study's procedures and requirements, answered questions, and obtained informed consent from parents and students. To increase reliability of the self-report measures, a bogus pipeline procedure was used,9,25 in which students were shown pictures of a spectrophotometer and provided a description of how their saliva samples would be analyzed and reported. Confidentiality was assured for all participants. Saliva samples were taken then students completed the baseline (pre-exposure) Smoking Knowledge And Behavior Questionnaire. Saliva samples and questionnaires were identified only by a code unique to each student.

Skills training/Assessment (Days 2,3,4,5,6,7, 8, 9). Members of the LST and VE groups met for one 50-minute session per week for eight weeks. Saliva samples were taken every other week at the beginning of a session. Each session focused on a different chapter from the LST Student Guide, with single sessions devoted to self-esteem and decision-making, and double sessions devoted to dangers of smoking, anxiety coping skills and assertiveness skills.

Members of the LST group met as a group. The group consisted of sharing personal goals, discussing workbook material, and role plays. The group was conducted by an experienced, independent cognitive-behavioral therapist unaware of the hypotheses of this experiment. During the two "anxiety coping" sessions, participants discussed the workbook material regarding anxiety and relaxation techniques, and listened to a 20-minute relaxation tape while lying down. During the two "assertiveness" sessions, participants discussed the workbook material and engaged in role playing exercises.

Before starting the first session, members of the VE group were given a one-half hour tutorial on how to use the VE apparatus. During this familiarization session, students were not presented with information related to smoking prevention. Following this orientation, members of the VE group met individually for eight sessions with a research assistant. The first 10 minutes were spent discussing personal goals and workbook material. The next 30 minutes were spent in the virtual world. The remaining time was used to put on and off the equipment, complete tests and questionnaires. Before entering the virtual world, the student completed the SSQ and the research assistant measured phoria. SSQ and phoria were measured immediately upon exiting the virtual world and about ten minutes later. The SSQ, but not phoria data, will be discussed in this paper. The usability questionnaire was given at the first and last session.

During the two "anxiety coping" sessions, participants discussed the workbook material regarding anxiety and relaxation techniques, and listened to a 20-minute relaxation tape while lying down. The condition of wearing the goggles was counterbalanced across weeks. While listening to the tape the first week, half the participants wore the goggles and the other half did not. During the second week, those who had used the HMD during week one did not do so during week two and vice-versa. The view through the goggles simulated the sensation of lying down in a virtual park. Subjects stared at a virtual sky, and if they turned their head to the right or left, they saw virtual grass. The virtual world also included the sounds of bird songs.

Two of the sessions included discussion about the workbook material on "assertiveness". Six of the eight sessions provided students opportunities to practice refusal skills with a virtual characters and to explore a virtual lung (see below).

Members of the Wait group did not have any sessions during this time period.

Post-exposure assessment (Day 10). Members of all three groups returned one week from Day 9 so they could provide another saliva sample, complete the first post-exposure smoking knowledge and behavior questionnaire, and participate in a focus group on smoking prevention programs. One-on-one interviews were conducted with six randomly selected students prior to conducting the focus group. The LST, VR and Wait groups met at different times.

Post-exposure assessment (Day 11). Members of all three groups returned six weeks from Day 9 so they could provide another saliva sample, complete the second post-exposure smoking knowledge and behavior questionnaire, and participate in a focus group on smoking prevention programs. One-on-one interviews were conducted with six randomly selected students before conducting the focus group. These six students were different from those participating in interviews on Day 10. The LST, VR and Wait groups met at different times.

Interacting with the virtual learning environment. Students put on a head-mounted display (HMD) to enter a virtual park (Figure 1). The HMD presents visual and auditory stimuli from the virtual park. The HMD also has a microphone so students can talk to virtual characters, a sensor on a gloved hand so the computer can draw a virtual hand that moves like the physical hand moves, and a hand-held controller to allow interactions with the computer simulation. The controller enables the student to move through the virtual park, initiate the speech recognition system, and grab virtual objects.

The virtual park consists of a number of objects, including trees, benches, and virtual characters who try to get the students to smoke cigarettes. The encounter begins with the character talking to the student (using the synthesized voice system). A menu of four different options is shown in the upper left screen. The student can respond to any one of the options (using the speech recognition system). When the character responds to the students' choice, another menu appears providing the student with four more phrases to say. This dialogue continues for several rounds until it ends in one of several ways. The response choices for the student range from accepting a cigarette or making the suggestion to smoke marijuana (less desirable responses) to refusals with offers of prevention information or alternative activities (more desirable responses). Students received different points for different responses. Because this paper deals with education in the virtual world and not skill acquisition, no other description of the students' interactions with virtual characters will be provided in this paper.

When the students have earned a certain number of points, they have the option of interacting with different versions of a virtual lung (Figure 2). In the virtual lungs, students can choose to see the effects of smoking cigarettes on the lungs as a function of smoking frequency and duration (e.g., a pack a month for a year, two packs a day for ten years). Students also have the option of interacting with objects in the virtual lungs to find out different pieces of information (e.g., "Less than one out of five kids your age smoke cigarettes", "Each cigarette you smoke takes six minutes off your life", "Smoking cigarettes makes it harder for you to run and play sports"). Students also have options of responding to multiple-choice quizzes covering information that has been provided. Students earn game points for all interactions in the virtual lungs.

Design

The major independent variable was the type of smoking prevention program (VE, LST group counseling, no program). The primary outcome measure was self report of smoking knowledge and behavior.5 In addition, members of the VR group were administered questionnaires for assessing usability of the VE program and presence of simulator sickness symptoms as a result of using the VE program.

Smoking Knowledge And Behavior Questionnaire. Two-way ANOVA was used to evaluate presence of group differences on this questionnaire. Independent variables were group (LST, VR, and Wait) and questionnaire item (60 items). The dependent variable was the difference between pre-exposure and post-exposure scores. The Joint Bonferroni test served as the post hoc analysis to indicate the differences in cell means from the group means. A bogus pipeline procedure was used to increase the validity of these self-report measures.9,25

Usability Questionnaire. Students' ratings on the questionnaire items were analyzed to determine whether they were significantly different from neutral, a rating of "5" on the 9-point scale. A one-sample t-test, with questionnaire item as the independent variable, was performed for each of the questionnaire categories. If significant differences were found (i.e., p < 0.05) for item category (e.g., "immersion"), one-sample t-tests were performed to determine whether specific items in each category were statistically different from "5". Criteria for these post-hoc comparisons were set at 0.05/n, where "n" was the number of items in that category.

Acceptability Questionnaire. Chi-squared analyses were conducted to determine differences in the frequency of students' responses to specific questions.

Simulator Sickness Questionnaire (SSQ). Repeated measures ANOVAs were used to evaluate whether simulator sickness symptoms resulted from exposure to the virtual learning environment. Independent variables were SSQ item (16), repetition of administration per each session (3), and number of sessions (5). (SSQ data from the two relaxation sessions were not analyzed and only five of the remaining sessions were analyzed for all participants to accommodate absences of two participants). If significant differences were found (i.e., p < 0.05), an adjusted Bonferroni test was used to determine whether specific cells were statistically different. Criteria for these post-hoc comparisons were set at 0.05/n, where "n" was the number of items in that category.

Results

Smoking knowledge and behavior questionnaire

Use and intent to use drugs. Pre-exposure data showed no significant differences between groups on the Smoking knowledge and behavior questionnaire when there were three groups of 24 students per group. However, by the end of the study, there were only 15 students per group, and an analysis of the pre-exposure difference scores showed differences on some items. Consequently, we used difference scores (post-exposure minus pre-exposure scores) as the dependent variable for subsequent analyses.

The post-exposure difference scores indicated no differences between the three groups in frequency of drug use, F(2,294) = 0.41, p=.663, no differences in type of drug used, F(6,294) = 0.22, p=.971, and no interaction between group and type of drug used, F(12,294) = 0.79, p=.659. The mean pre- and post-exposure ratings for all three groups ranged from 1.09 to 1.28, where "1" represented "never used drugs" and "2" represented use of drugs a few times but not in the past year. The mean ratings indicated that students entered the study as non-users and left as non-users.

The post-exposure difference scores also indicated no differences between the three groups in intent to use drugs, F(2,252) = 1.69, p=.186, no differences in intention for using different kinds of drug, F(5,252) = 0.5, p=.778, and no interaction between group and intent to use different types of drugs, F(10,252) = 1.57, p=.114. The mean pre- and post-exposure ratings for all three groups ranged from 1.11 to 1.44, where "1" represented "definitely no intent to use drugs" and "2" represented "probably no intent to use drugs". The mean ratings indicated that students entered the study with no intention to use drugs and left with no intentions to use drugs.

Perceptions of peer and adult use of drugs. Participants in the VE group showed more accurate information concerning peer drug use as a result of participating in the experiment. Analyzing the difference scores indicated no main effect for type of drug, F(5,252) = 0.21, p=.956, nor an interaction between group and type of drug, F(10,252) = 0.78, p=.651. However, there was a main effect for group, F(2,252) = 4.86, p=.008). The mean ratings changed from 2.4 to 2.2 for the VR group, 2.3 to 2.4 for the LST group, and 1.8 to 2.1 for the Wait group, where "2" indicated less than half of their peers used drugs and "3" indicated about half of their peers used drugs. Post hoc analyses indicated that the VR group’s perceptions of substance use by their peers significantly decreased and became more realistic, t = 2.97, p = .003, while the Wait group’s perceptions of substance use by their peers significantly increased and became more distorted, t = -2.3, p = .022.

Participants in the VE group also showed more accurate information concerning adult drug use as a result of participating in the experiment. Analyzing the difference scores showed no main effect for type of drug, F(5,252) = 1.58, p=.165, nor an interaction between group and type of drug, F(10,252) = 0.81, p=.619. However, there was a main effect for group, F(2,252) = 7.54, p=.001). Post hoc analyses indicated that the VR group’s perceptions of substance use by adults significantly decreased and became more realistic, t=3.01, p=.0028 while the Wait group’s perceptions of substance use by adults significantly increased and became more distorted, t=-3.63, p=.00035.

Attitudes toward smokers and smoking. This section assessed students’ attitudes towards smoking. Statements about smoking were presented and the students indicated the extent to which they agreed or disagreed with the statements. There was no main effect of group, F(2,502) = 0.31, p=.735, nor of questionnaire item, F(11,502) = 1.59, p=.097. However, there was a significant interaction between group and item, F(22,502) = 1.74, p=.020. Post hoc analyses indicated significant interactions for only two items.

On one item, the LST group’s preferences to date non-smokers significantly increased from their pre- (mean of 2.7) to post-exposure (mean of 1.7) answers, t=3.17, p = .0015. This could be related to the group setting environment for the LST group, where group discussions of smoking effects such as bad breath and smelly clothes may have had greater impact.

On the second item, the VR group was significantly more likely to agree with the statement "becoming a smoker reflects poor judgment", t=3.41, p = .0007, and the Wait group was more likely to disagree with that statement, t=2.58, p = .01.

The mean pre- and post-exposure ratings for all three groups, collapsed across questionnaire item, ranged from 1.69 to 2.07, where "1" indicated Strongly Agree with negative statements about smoking, and "2" indicated Agree. The mean ratings indicated that in general students entered with negative attitudes towards smoking and left with negative attitudes towards smoking. The items showing significant changes were those that had initially indicated agreement with positive aspects of smoking, leaving room for improvement during the eight-week study.

Decision making. The items in this section assessed the students’ thoughtfulness during decision making. These items began, "When I have a problem or need to make an important decision I:", and a list of preparations was given, such as "Get the information needed to make the best choice" and "Think about what will happen for each choice before doing anything". Answer options were the following (with the corresponding value given in parenthesis): Never (1); Almost Never (2); Sometimes (3); Almost Always (4); Always (5).

Analyzing the difference scores revealed no main effect for group, F(2,210) = 1.34, p=.264, questionnaire item, F(4,210) = 0.33, p=.860, or the interaction between group and item, F(8,210) = 0.3, p=.965.

Coping with anxiety. The items in this section assessed the way the students dealt with anxiety. These items began, "When I feel anxious I:", and a list of anxiety reducing techniques was presented that included options such as muscle relaxation and breathing exercises. Answer options were the following (with the corresponding value given in parenthesis): Never (1); Almost Never (2); Sometimes (3); Almost Always (4); Always (5). There was no main effect for questionnaire item, F(4,210) = 0.22, p=.930), nor for the interaction between group and item, F(8,210) = 1.06, p=.392. However, analyzing the difference scores revealed a significant main effect of group, F(2,210) = 3.36, p=.037. Post hoc analyses indicated that the VR group showed significantly more intention to use the relaxation techniques, t = 2.43, p = .015.

Usability questionnaire

For each section of the usability questionnaire, a one-sample t-test was performed to compare the sub-section’s grand mean ratings to neutral or "5".

Overall Effectiveness of the Test and Instructions. The mean rating for these items was 7.72, t(207) = 20.54, p = .000. Post-hoc analyses showed most of these items to be significantly positive as well, including "It was fun to be in the virtual world" (mean of 7.81), "Being in the virtual world taught me about the dangers of smoking" (mean of 8.06), and "I would like to be in the virtual world again" (mean of 7.5).

Aesthetics. The mean rating for these items was 6.4, t(191) = 7.78, p = .000. However, post-hoc analyses showed only two of these items to be significantly positive. These were "I liked the colors in the virtual world" (mean of 7.25) and "I liked how the virtual lung looked" (mean of 7.75). The rest of the items, while all with mean ratings greater than "5", did not meet criteria for statistical significance. These included items such as "I liked how the virtual park looked" (mean of 6.56), "I liked the way the characters in the virtual world looked" (mean of 6.44), and "I liked how my hand looked in the virtual world" (mean of 5.19).

Virtual Displays. The mean rating for these items was 6.86, t(271) = 12.89, p = .000. Post-hoc analyses showed most of these items to be significantly positive as well, including "It was easy to use the virtual reality equipment" (mean of 8.12), "It was comfortable wearing the goggles" (mean of 7.56), and "I understood the synthesized voice" (mean of 7.06), and "It was easy to read the words on the screen with the goggles" (mean of 7.19). However, other items were not rated as highly. These included items on the realism of the interaction such as "The way the characters spoke to me seemed realistic" (mean of 5.81) and "When I grabbed virtual objects it felt like I was grabbing real objects" (mean of 4.94). The latter rating is not surprising; while there were kinesthetic sensations from interacting with the hand-held controller, there were no tactile or force feedback devices in the VR system.

Virtual Controls. The mean rating for these items was 7.14, t(223) = 13.16, p = .000. Post-hoc analyses showed most of these items to be significantly positive as well, including "It was easy to move around in the virtual world" (mean of 8.06), "If I was refusing an offer to smoke in real life, I would say things just like the way I spoke to the virtual characters" (mean of 7.47), "My conversations with the characters seemed realistic" (mean of 7.25), and "It was easy to use the menus to have conversations with the virtual characters" (mean of 7.19). However, other items were not rated as highly. These included items on the realism of the interaction such as "When I talked with the characters it felt like I was talking with a real person" (mean of 6.81).

Immersion. The mean rating for these items was 6.17, t(143) = 4.7, p = .000. However, post-hoc analyses showed no item to be significantly positive.

Acceptability questionnaire

Students had no preference for video games over the VR program (X2 = 3.4, p = .33), thought the VR program should be used at school (X2 = 12.5, p = .002), and indicated preferred frequency of using the VR smoking prevention program one to three times per week (X2 = 11.5, p = .02).

Students thought their friends would enjoy using the VR program (X2 = 9.12, p = .01), thought that being immersed in the virtual world was the most fun aspects (X2 = 14.0, p = .007), and found little to make the experience more fun (X2 = 18.38, p = .001) or more interesting (X2 = 24.0, p = .000).

Simulator sickness questionnaire

To determine whether there was an effect of session on the item ratings, a repeated measures ANOVA was conducted with session as one independent variable (5 sessions), SSQ item as a second independent variable (16 items), and ratings as the dependent variable. There was no main effect of session, F(4,561) = 2.37, p=.064), nor for the interaction of session by questionnaire item, F(60,840) = 0.87, p=.74). Therefore, participants' mean ratings across session were used in subsequent data analyses.

Two different subsequent analyses were conducted. One analysis was conducted to evaluate whether the first post-exposure symptom ratings were significantly different from zero, which would indicate whether exposure to the goggles and virtual world caused simulator sickness symptoms. The second was conducted to evaluate whether the second post-exposure symptom ratings scores were significantly different from zero, which would indicate whether symptoms resulting from exposure had disappeared. The results are shown in Table 1. To reduce Type I error, the criteria for significance was determined to be .05/16 = .003. All mean ratings were less than "1", indicating minor simulator sickness symptoms. The results indicate the symptom ratings were not statistically different from "0", although items 3, headache, and 4, eyestrain on the first post-exposure measure were close.

Conclusion

Evaluations during this pilot study indicated effective presentation of prevention information as well as ease of use and acceptability of the virtual learning environment. Other groups have indicated the potential benefits of virtual environment technology for treating phobias such as fear of flying,15,20 fear of heights,19,23 and fear of spiders,8 and there is interest in using the technology in other clinical and mental health arenas.13,22 This pilot project shows the utility of virtual environment technology for promoting mental health through acquisition of prevention education and skills.

Performance.

While we did not expect to find differences in use of cigarettes and other drugs in an eight-week study using relatively few students, we did expect to find differences in attitudes, education, and intent to use. However, on average, students in all three groups started with negative attitudes toward smoking and low incidence of use and intent to use; there was room for worsening behavior and attitudes, but not for better. While there was significant evidence that students in the VLE group did improve in some areas, there may not have been enough time to show such changes in behavior, especially since the greatest changes in behavior would be expected in 8th graders.14 We would expect longer-term follow-up of these students to indicate even more advantage for VLE. Furthermore, the fact of previously established negative attitudes toward smoking can probably be attributed to student participation in other prevention programs like DARE.

It also should be noted that these results are confounded by an experimental design in which the LST group participated in a group learning environment and the VR group participated in a one-on-one individual learning environment. These differences in learning environment may have contributed to differences in results. Subsequent studies will disambiguate the results.

Despite the relatively small sample size and short time period for the prevention education, there were significant benefits of using the VE program. Teens' perceptions of peer and adult use of cigarettes and other drugs have an important impact on teens' use. More effective or compelling presentation of this information to correct their perceptions, as with the VR program in this study, should have more positive impacts on their behavior.

While we expected larger changes in attitudes, we did not observe them. Again, these students started with negative attitudes toward smoking and for the most part maintained them. Those questionnaire items that showed improvement, such as the relationship between smoking and poor judgment were those initially indicating more positive attitudes toward smoking.

It is important to notice that in areas in which there was a virtual representation of information (information about peer use, physiological effects, and anxiety reduction techniques), there were positive changes resulting from the using the VR program that did not occur with the LST program. In areas in which there was no virtual representation, such as with the questionnaire items on decision-making, there was no difference between the VR and LST programs (and there was no positive effect). These data provide further evidence of the added utility of the virtual learning environment for a smoking prevention program.

Ease and effectiveness of use.

The usability evaluations showed that participants liked using the virtual learning environment, were able to see and hear stimuli sufficient to perform the tasks and were able to easily use the manual and speech controls to interact in the virtual world.

The design team was concerned with providing functional fidelity, in which task-relevant cues were provided in the environment, rather than providing physical fidelity, in which all aspects of the physical stimuli were matched by virtual cues. Actual physical environments provide rich multidimensional patterns of sensory inputs to an observer. It is not necessary, however, to realistically represent all aspects of the physical environment in the VE because not all information that is available in either the physical or VE is actually functional; i.e., essential for performing the task.6,27 In fact, it is difficult to provide physical realism to simulated environments, and it may not be necessary.21,24 For instance, training with flight simulators appears to be most effective when the simulator is designed to provide functionally relevant rather than objectively correspondent stimulus cues;17 what is critical is that the right task cues are presented in the virtual environment.

Designing the VR program for this pilot study concentrated on effectiveness of presenting information (e.g., legibility of text and comprehension of the synthesized voice) and effectiveness of the manual and speech controls. These areas were positively rated. In contrast, there was little expectation for the aesthetics of the computer graphics to be rated particularly well because there was not as much effort spent on these areas while developing the pilot project. Similarly, there was no expectation of positive ratings for questions related to the realism of the interaction. The usability evaluations showed ease of use and effectiveness in expected functional areas. Despite their relatively low ratings of the aesthetics (though still positive overall), students indicated their enjoyment in participating in the virtual world. The usability results indicate that the design team was successful in providing functionally relevant cues.

Acceptance.

Students were overwhelmingly in favor of using the VR tool at school and were very positive about using it often. Combined with no significant simulator sickness symptoms resulting from use, results indicated high acceptability. These data supported the hypotheses that the VE technology would be compelling and accepted by teens, and that they would be more likely to use this technology, thus providing greater opportunities for exposure to critical prevention information and for practicing assertiveness and other skills.

Future work

These data indicated that this VE application is a promising tool for keeping teens healthy. Subsequent studies will evaluate utility of the virtual learning environment as an integrated component of group prevention programs, like LST and DARE, for a larger sample size and for a longer period of time.

Acknowledgments

This research was supported by the National Cancer Institute under contract number 1-R43-CA74603-01. We appreciate their support. We thank Gil Botvin, Jennifer Epstein, Judith Lomba and Heather Turey for program guidance; Linda Perez and Pajaro Valley Prevention and Student Assistance for recruiting study participants; Derek Rucker for data collection; Eddo Stern and Edward St. Lawrence for computer programming; Helene Wood, Wellness and Rehabilitation Center and Watsonville Community Hospital for providing facilities. Any opinions, findings, conclusions or recommendations expressed in this publication are those of the author and do not necessarily reflect the views of the National Cancer Institute.

Author note

Correspondence concerning this article should be addressed to: Kenneth Nemire, Interface Technologies Corporation, 1840 - 41st Ave., Ste. 102, Capitola, CA 95010 USA

831-688-3084 (tel), 831-688-3084 (fax), knemire@appliedve.com.

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Table 1. The mean ratings (and p values) of simulator sickness symptoms for the first and second post-exposure measures indicated that exposure to the virtual learning environment did not cause significant symptoms