This document describes a proposed online virtual environment program to help teens quit smoking. The program would use virtual reality exposure therapy and cue exposure therapy. Teens would navigate virtual environments like a home and school dealing with smoking cues and peer pressure. The program would track craving levels, lung health, energy levels and number of smoke-free days. It would include mini-games to help manage cravings by providing distraction. Data would be collected to evaluate the program's effectiveness in educating teens about smoking cessation.

1. IMI
9565 Waples Street, Suite 200
San Diego, CA 92121
Tel: (858) 642-0267
An Internet-based Virtual Environment to
Curb Teen Smoking
Team IMI: Kenneth Gao, Dr. Brenda Wiederhold, Lingjun Kong Dr. Mark Wiederhold
Phase I Submission for Robert Wood Johnson Foundation: Games to Generate Data
Date: February 22, 2013
Most smoking cessation programs are geared
Introduction and Background towards adults, and there has not been enough effort
put in to teen smoking cessation programs [Sussman
Smoking has increasingly become a burden on et al. 2006]. IMI team wants to create an online
America’s health and economic status. Tobacco use smoking program to help adolescents to kick the
in the United States results in over 440,000 deaths habit. Adolescents favor an informal and convenient
every year, accounting for the deaths of 1 in every 5 tobacco cessation support. Teenagers are more
Americans, and is the leading preventable cause of comfortable hiding behind their computers and they
premature death [NIH State-of-the-Science Panel, feel less inhibited in virtual environments as opposed
2006]. 80% of adult smokers started smoking before to face-to-face interaction. The online virtual
the age of 18. Although these youths have not environment has been designed based on engaging
become regular smokers, they are already addicted. to user’s attention, but not to the point of distraction.
The younger they are when they begin to smoke, the
more addicted they become to nicotine [Klein et al. Cue exposure therapy (CET) has been used to treat
2005]. Some teens don’t even realize they are addictive behaviors. This type of therapy uses
addicted and some are in denial. It has become repeated exposure to eliminate the association of
something their body needs and craves. Since they smoking with objects and situations [Lee et al., 2004].
are still young, they do not believe they are at risk for The Virtual Reality Exposure Therapy has been
smoking related health issues and feel they are critical for virtual environment designs. IMI’s program
invincible. They believe they can quit at any time would use virtual environments containing smoking
therefore they do not seek assistance in quitting. cues such as packs of cigarettes, ashtrays, and peer
Those who would like help quitting, are unfamiliar pressure. This is done so users can see what triggers
with smoking-cessation programs and are concerned their cravings. Once they realize what causes them to
over parent involvement, confidentiality, and the want to smoke, they can understand why they crave a
ability of counselors to relate to their experiences cigarette and learn to distract themselves from
[Woodruff et al. 2001]. smoking. In the first virtual environment, smoking
cues are placed around teenager’s home. In some
Some of the reasons adolescents smoke is because cases, users can look at the objects that increase
it gives them a “buzz,” it gives them something to do their craving. In other cases, users have the option to
when they are bored, it makes them feel more throw away the objects. In the second environment,
relaxed, they think they look “cool” and more mature, users are at school. There, they will deal with the
it decreases their appetite helping them to lose pressure from their peers to smoke. When offered a
weight, and it helps them fit in with their friends. They cigarette, they can choose to either accept the offer,
are concerned that if they quit smoking, they will not or to fight their craving and decline the offer.
be able to relax and will be in a bad mood. They will
lose an activity that helps them to pass time. They will
also have to change their social life if they discontinue
smoking [The Smoking Zine, 2006].

2. The first component is the “HUD”. The “HUD” layer
System Components and exists through out the whole simulation. It’s used to
Architecture update the status of the simulation performance. The
“HUD” consists of multiple small components, which
Having analyzed development constraints and key include “Stamina”, “Craving”, “Lung”, and
features, our development team defined conceptual “Timeframe”. These components change depending
models during the initial design stage on the behavior of other components.
System Diagram The second component is the “UserInterfaceMain”.
The “UserInterfaceMain” is responsible for displaying
The Teen Smoking system consists of a web server all the main scenarios of the simulation. It is divided
which includes database storing user performance into 2 sub layers: “Home” and “School”. Both “Home”
and program information, and client computers for and “School” have multiple components, and each
user accessing the program. To access the website, component interacts with the “HUD” layer and the
the client computer should have internet access “MiniGame” layer. The “UserInterfaceMain” layer also
capability. The web server uses a server-side handles transition from one component to another.
scripting language -- PHP for creating web program
which dynamically loads the program status, tracks The third component is the “MiniGame”. This layer
user’s performance, and saves user data into the consists of the entire mini games. Each mini game
server database. shares some attribute with the “HUD” and the “Cues”
layer. “MiniGame” layer is responsible for loading and
Component Diagram unloading the logics of mini games.
Teen Smoking development is built upon a The last component is the “SmokingCue”. It’s the
hierarchical structure. Each structure is divided into bridge between the “UserInterfaceMain” to the
multiple components. Each component has its own “MiniGame”. It also serves as trigger to the “HUD”
purpose and attribute. At the top of the structure, layer, which enable or disable all the sub components
there’s main layer “MainTeenSmoking”. The to the “HUD”. Overall each component serves their
“MainTeenSmoking” layer is responsible for purposes; they all are separated by functionalities,
managing all the lower structure and keeping track of but connected via the “MainTeenSmoking” layer. The
progresses, high score and loading information. It’s following component diagrams described detailed
used to reset and initialize all information through out system components
the simulation. There are four components that
directly connected to the “MainTeenSmoking”.
Figure 1. System
Diagram of Teen
Smoking System,
showing connections
between users and
server where data is
collected.

3. Figure 2. Component diagrams of the (a) main layer, (b) user interface, and (c) minigames.

4. Design
The followings are the sketches for the initial design:
1. After the start up screen, user will be in his/her own bedroom. The first thing he/she must do before leaving
his/her room is clicking on the calendar and picking a quit date. He/She will be able to tell time by a sun icon.
For day one, it will be a Sunday so he/she will be at home the whole day.
2. There will be some smoking cues everywhere in the house. The ashtray and cigarette will be displayed on the
table. On the lower right corner is the ‘craving’ status bar. It indicates the player’s current craving level to
cigarette. When he approaches smoking cues like ashtray or coffee, the bar goes up. User can have
difference actions to deal with the cravings. User might want to clean out the ash tray and while doing so,
he/she end up breathing in some of the ashes causing his/her lungs to darken. When a cigarette is offered,
the user can take it and the craving immediately lowers. If the user wants to fight the craving, a mini game will
be played. The craving will then lower if the game is won, but not as much as if he or she had smoked a
cigarette.

5. 3. Activities user can do for resisting the craving will be to take a bath, cook in the kitchen, call a friend, and play
a dance game. For taking a bath, the user will lie down in the tub and his/her feet will be showing. In the water,
there will be rubber ducking floating around that he/she can play with by squirting water at them to temporarily
sink them. To cook in the kitchen, the user will see a recipe on the fridge, open the fridge to collect the items,
and cook the food. User can make pasta or a sandwich. For the pasta, the ingredients are on the refrigerator
door. The user must look at it, and then open the door to collect the ingredients. If user forgets the ingredients,
then he/she must close the door to look at the recipe again.
4. At home, user can flip open their cell phone and invite some friends over. When the user uses his/her cell
phone to call a friend, all their friends will be busy for Phase I of the game so the user can call, but will get the
voicemail. The dance game will be in the living room. User can turn on the TV and the game is a simon says
type of game. Dance arrow keys light up in a specific order and the user has to copy the pattern. After doing
two activities, the user has no other choice but to go to bed for the next day. On the following days, the user
has to go to the garage and click on the car to get to school.
5. The loading screen for the transition from home to school will be a map with dots showing the car traveling.
When user gets to school, he/she will be able to play with the radio and windshield wipers. If they mouse over
the ash tray or cigarette lighter, the craving bar will go up. If the door handle has been clicked, user will exit
out of the car and navigate to the classroom. When user gets to class, the clock will be seen and it will move
quickly showing a lot of time is passing.

6. 6. During lunch, user can either go to the school bathroom, or hang out with his/her friends. In the bathroom,
there will be people smoking. One of the classmates will offer a cigarette. After that, a mini game will start. If
the user wins the mini game, he or she will win in the attempt to fight the craving. If he or she loses, then they
will give in to the craving. If instead the user eats lunch with friends, one of the friends will offer a cigarette,
and a mini game will start. After lunch, the user goes back to class and the spinning clock is shown again.
The homework will come from facts written on the board in the classroom. After user gets back home from
school, he/she will have to answer questions that came from the facts on the board. In the afternoon, school
is over and the user drives back home.
7. One of the activities must be doing homework before user gets to the bed. The homework will consist of a
poster with information on smoking cigarettes. The user is given a set amount of time to look at it. Afterwards,
user is given questions with multiple choice answers. On other nights, the posters and questions will be
different. After doing their homework, the craving for cigarettes will increase slightly. On day 3 of not smoking,
a message will appear saying, “Congratulation! You’ve been Smoke-Free for 3 days…” user will then be given
a fun mini game to play.
Virtual World Development
The followings are the conceptual mockups of the first
stage of TeenSmoking virtual environment:
Figure 3. bedroom,
kitchen, and
bathroom.

7. We believe that one of the first steps of making our or eat to regain energy. An additional time-of-day
smoking cessation program effective is to capture the indicator icon is also displayed to help guide the
interest of the users and keep them interested. player to certain activities and keep track of the day.
Therefore, with teenagers being our target audience, According to many smoking cessation strategies and
we cater to their generation by creating new age tips, the selection of a quit date is one of the first
environments using high polygon 3-dimensional steps to successful smoke quitting. At the start of the
models and vectors that provide a very polished and program, user is in his or her bedroom, which is
trendy feel. To further accommodate our audience, where he or she must select a quit date from the
we chose scenarios and situations with which they provided calendar before being able to participate in
can easily relate. For example, the two main other activities. Another smoking cessation tip is to
environments are a teenager’s home and school, remove all smoking paraphernalia in the environment
which are places where teenagers typically spend the if possible, which is what the player must do in the
majority of their time. We chose a first person view to game to help decrease the craving level. The user will
add realism and immersion to the game. find various smoking cues, such as cigarettes, coffee,
alcohol, and ashtrays, placed throughout the house.
Figure 4 - School Environment in Vectorized Animation Figure 5 - Player Could Face Peer Pressure from Fellow
Schoolmate
Throughout the program, user will see several They will then be given choices on what to do with
smoking cessation related indicators on the screen. those paraphernalia. At school, the user will be faced
These being a craving bar, stamina bar, lung icon, with peer pressure and his or her craving when other
and smoke-free day counter. Since craving plays a students offering cigarettes.
significant role in smoking cessation, we want to
assist the user in learning to control his or her craving The user will also discover several mini-games and
level. The craving bar shows the user his or her activities are available to help him or her deal with the
craving level for smoking a cigarette, which the user craving. Most of these activities distract and reduce
must keep at a low level by either finding alternative smoking cravings, but some games include smoking
activities to do or simply giving in to their craving and cues to challenge the user’s real-life craving. One of
smoking, just as they would in real life. If the user the activities in the home is the option of taking a
chooses to smoke, the lung icon, (which ranges from bath, which is a method of suppressing craving. While
a shade of beige to black) will become darker and the the playing is “taking a bath,” he or she plays a mini-
smoke-free day counter will be set to zero. If he or games where the user tries to acquire as many points
she fails to keep the craving level low, the bar will turn as possible by shooting rubber ducks with a water
red, and the user will hear a heart beating increasing gun. Not only does this game distract the user from
in loudness and the screen will fluctuate between wanting to smoke, but also to entertain him or her.
bright and normal conditions. One of the effects of Another activity in the house is making a sandwich.
smoking is a decrease in energy, which is where the While smokers are eating, he or she normally does
stamina bar comes into play. The stamina bar keeps not crave to smoke, which is why the activity reduces
track of the user’s energy level, which determines the the players craving level in game. However, after
number of activities he or she can participate in. Each eating, the craving level will increase since that is
day it starts off with at a full level and decreases when many smokers tend to smoke. A drumming
gradually as time goes by. Doing activities also uses game, where the user is required to remember and
stamina. The decrease rate is dependent on the follow the drumming pattern, is also included in the
lung condition—the healthier the lung (brighter), the house. The memorization involved in the game
slower the stamina decreasing rate. When the increases immersion, therefore distracting the user
stamina reaches the minimum the player must sleep from his or her cravings.

8. score is, the more likely that they received
In real-life, if one wants to maintain or improve the educational knowledge on quitting smoking.
lung condition, one could do physical exercise. It is
essentially the same in game. If the user decides to Non Parametric scores such as Signed Rank test and
take a smoke, his/her lung icon turns a little darker Wilcoxon Signed rank will be used. Wilcoxon Signed
each time. Only by stop smoking and doing exercise rank will confirm that if there were significant
in game would improve the lung condition and turn differences among the group scores in the Teen
the lung icon to become normal again. These smoking Pre/Post Test results for the total score
messages, together with other smoke quitting tips, every questions in the questionnaire dropped after
will be carried across to teenagers in a fun and the participants played the game. It indicates that
engaging way. they disagreed with the bad habits of smoking, or
decided to spend less effort in activities which
When the user is on school grounds and he or she increases their smoking cravings
turns down cigarettes offered by peers, the user is
faced with the challenge of rejecting the craving by In our program, the players could choose to do
playing a mini game. If he or she wins the game, user physical exercise or to smoke. Before they played the
successfully denied the craving. However, if the user game, we will measure whether more subjects were
loses, this translates to him or her giving into the educated from the video game: physical exercise
craving and smoking, which also leads to the reset of played a positive role in assisting quitting smoking.
the smoke-free day counter. User would realize the We will also create an environment to the players that
challenge they face on quitting smoking, but with they either choose to smoke, or do something else to
determination and the right attitude, one will keep them busy. We also let players to decide
eventually succeed, just like in real-life. These games whether they want to choose a quit date or not in the
are randomly selected to make the program more game. So, we will ask player’s opinions on “setting a
appealing to the user since he or she will be at school quit date helps you to quit”. The virtual environment
for multiple days. They are also more challenging leads the players think about “once you decide to
than the games in the home because they include quit, it is easy to turn down a cigarette”. We also let
smoking cues that tempt the user. the players experience that “craving increases when
you are bored” in the game.
Statistic of the user’s condition and his/her taken
actions are being recorded and displayed on the
right-hand side of the main screen. These include the
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