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The effect of repeated exposure to virtual

gambling cues on the urge to gamble
ARTICLE in ADDICTIVE BEHAVIORS SEPTEMBER 2014
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Addictive Behaviors 41 (2015) 6164

Contents lists available at ScienceDirect

Addictive Behaviors

Short Communication

The effect of repeated exposure to virtual gambling cues on the urge

to gamble
Chan-Bin Park a,e, Su Mi Park a, Ah Reum Gwak a, Bo Kyung Sohn a,b, Jun-Young Lee a,b, Hee Yeon Jung a,b,
Sam-Wook Choi c, Dai Jin Kim d, Jung-Seok Choi a,b,
a

Department of Psychiatry, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea

Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
Department of Psychiatry, Gangnam Eulji Hospital, Eulji University, Seoul, Republic of Korea
d
Department of Psychiatry, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
e
Center for Defense Management, Korea Institute for Defense Analyses, Seoul, Republic of Korea
b
c

H I G H L I G H T S

VR casino environment was able to evoke a signicant urge to gamble.

The participants' urge to gamble was the strongest in playing a casino game scene.
The urge to gamble decreased continuously as a function of repeated exposure.
VR-CET combined with relaxation training can reduce recreational gamblers' urges.

a r t i c l e

i n f o

Available online 28 September 2014

Keywords:
Gambling
Virtual reality
Cue exposure therapy
Relaxation training
Urge

a b s t r a c t
Introduction: This study aimed to investigate the effectiveness of using a virtual reality (VR) casino environment
in cue exposure therapy (CET) for gambling. The main objective of this study was to assess the ability of ve VR
casino cues to elicit subjective reactions and physiological responses that can be used within the CET paradigm. A
second objective was to analyze changes in participants' urge to gamble after repeated exposure to a VR casino
program and relaxation training.
Methods: Twelve recreational gamblers were exposed to ve virtual environments with casino-related cues that
reproduced typical gambling situations. Self-reported subjective urges and psychophysiological responses were
recorded during exposure.
Results: All virtual environments with casino-related cues generated craving in recreational gamblers, whereas
no increase in the psychophysiological variables was observed. In addition, urges to gamble elicited by VR casino
environment reduced through repeated exposure and relaxation training.
Conclusion: These ndings provide evidence of the effectiveness of VR for simulating casino environments in the
treatment of gambling.
2014 Elsevier Ltd. All rights reserved.

1. Introduction
Pathological gambling (PG) is a progressive and recurrent maladaptive pattern of gambling behavior characterized by increased preoccupation with gambling activities, loss of control over such behavior, and
continued gambling despite problems in social or occupational functioning (American Psychiatric Association, 2000). It is associated with
Corresponding author at: Department of Psychiatry, SMG-SNU Boramae Medical
Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 156-707, Republic of Korea. Tel.: +82 2
870 3461; fax: +82 2 831 2826.
E-mail address: choijs73@gmail.com (J.-S. Choi).

http://dx.doi.org/10.1016/j.addbeh.2014.09.027
0306-4603/ 2014 Elsevier Ltd. All rights reserved.

signicant nancial losses and disrupted interpersonal and familial relationships (Blanco, Hasin, Petry, Stinson, & Grant, 2006).
Cue exposure therapy (CET) refers to repeated exposure to drugrelated cues aimed at reducing reactivity to such cues via extinction
(Conklin & Tiffany, 2002). Craving and cue reactivity have been conceptualized as classically conditioned responses, and CET is based on the
notion that prolonged and repeated non-reinforced presentation of
cues will result in a gradual diminution of the urge through Pavlovian
extinction. Several authors have reported that virtual reality (VR) is an
effective approach to reducing cue reactivity related to alcohol, cannabis, and cigarettes (Bordnick, Graap, Copp, Brooks, & Ferrer, 2005;
Bordnick et al., 2008, 2009; Choi et al., 2011).

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C.-B. Park et al. / Addictive Behaviors 41 (2015) 6164

Symes and Nicki (1997) tested the effect of repeated exposure to

stimuli associated with gambling on the urge to gamble and perceived
self-efcacy. During each session, two probable pathological gamblers received ve exposures to relevant stimuli to provoke the urge to gamble.
Data obtained during each session showed a reduction in the urge to gamble over the course of certain sessions. Another case study conducted by
Tolchard, Thomas, and Battersby (2006) found a reduction in the urge
to gamble during a single exposure session. However, the case-study experimental design used in these two studies restricts the generalization of
their ndings (Giroux et al., 2013). One study reported the effectiveness
of a VR cue exposure paradigm for pathological gamblers (Giroux et al.,
2013). Ten participants moved throughout a virtual bar with ve video
lottery terminals ve times. Whereas the desire to gamble signicantly
increased when participants transitioned from the practice environment
to the gambling environment, this study was unable to conrm the process of extinction because it consisted of only a single 20-min session.
In this preliminary study, we aimed to investigate the feasibility and
viability of a VR casino environment for the use in repeated CET to treat
gambling. The main objective of this study was to assess the ability of
ve VR casino cues used within the CET paradigm to produce subjective
reactions as well as physiological responses. A second objective was to
analyze changes in participants' urge to gamble after several sessions
of repeated exposure and relaxation training.

biofeedback unit and the BioGraph Inniti ver. 4.0 software (ProComp;
Thought Technology Ltd., Quebec, Canada). Detailed information on the
psychophysiological measures was also described in the previous report
(Choi et al., 2011).

2. Materials and methods

2.4. Data analysis

2.1. Participants

All statistical analyses were conducted with SPSS ver. 17.0 (SPSS Inc.,
Chicago, IL). A repeated-measures ANOVA was used to evaluate differences in the target variables among the scenes in Experiment 1 and
among the sessions in Experiment 2. LSD post hoc comparisons were
used for comparing the mean urge at each moment. Statistical analysis
was two-tailed, and signicance was set at p b 0.05.

We recruited subjects through advertisements posted at an outpatient clinic. Those eligible to participate had a basic interest in gambling
for recreational purposes; score on the South Oaks Gambling Screen
(SOGS; Lesieur & Blume, 1987) of 4 or less; and no history of excessive
gambling. One reason for recruiting recreational gamblers was that
they have reported levels of cue-elicited urges similar to those reported
by pathological gamblers in response to the videotaped excitinggambling scenarios used in a previous study (Sodano & Wulfert,
2010). Twelve male participants were enrolled in this study. The sample
had an average age of 32.32 (SD: 6.43) years, and their average number
of years of education was 16.2 (SD: 1.95). This study was conducted in
accordance with the Declaration of Helsinki. The Institutional Review
Boards of the SMG-SNU Boramae Medical Center approved the study
protocol, and all subjects provided written informed consent prior to
participation. Each participant received compensation of approximately
$30 for participating in each session of the study.
2.2. Instrument and variables
2.2.1. Virtual environment
The three-dimensional (3D) VR environments were implemented
on a high-speed PC computer, and visual stimuli were delivered to
three surround screens (80 in.) via three LCD digital projectors
(LX400; Christie Digital Systems, Cypress, CA, USA). A motion controller
(WING; iStation, AnYang, Republic of Korea) was interfaced with the
computer to control the 3D features and measure subjective urges.
Urge to gamble was assessed by means of a visual analogue scale
(VAS) that was incorporated in the virtual environments. Participants
were asked to rate the strength of their urge at a precise moment
using a scale ranging from 0 (no desire) to 100 (intense desire). Urge
was assessed pre-exposure, during exposure, and post-exposure.
Detailed information on the virtual environment was described in the
previous report (Choi et al., 2011; Park et al., 2014).
2.2.2. Psychophysiological measures
Psychophysiological response data (electromyography (EMG), skin
conductance (SC), and heart rate (HR)) were acquired during each VR
exposure session using the multi-modality encoding system of the

2.3. Procedure
2.3.1. Experiment 1
Before the session started, baseline psychophysiological measures
were recorded for each participant 3 min prior to exposure to the virtual
environments. After the baseline measurements, participants watched a
3-min relaxation video, followed by each of ve casino scenes. Psychophysiological responses were monitored throughout the session. One
session lasted about 40 min. Snapshots of the restful video and 5 casino
scenes are displayed in Fig. 1.
2.3.2. Experiment 2
Participants in Experiment 1 engaged in ve weekly gambling-cue
exposure sessions. Experiment 2 involved an additional ve sessions
that followed the identical procedures used in Experiment 1. To control
for the carryover effect of craving that accumulated over the course of
exposures, the order of the ve casino scenes in each session was
counterbalanced.

3. Results
In the rst section of Table 1, Experiment 1 shows the mean subjective gambling urges reported by participants, as well as their psychophysiological responses before and after exposure to the virtual
environments. According to these data, all scenes with casino cues
succeeded in increasing participants' subjective urges. The results of
the repeated-measures ANOVAs revealed signicant differences in subjective urge across scenarios (F(3.83, 42.13) = 8.19, p = .00). Post hoc
comparisons showed the mean urges in the casino scenes differed signicantly from those during the rest of the scenarios. The virtual scene
eliciting the most pronounced urges involved playing a casino game.
In contrast, no signicant changes in the psychophysiological measures
across the scenarios were observed.
In the second section of Table 1, Experiment 2 presents the changes
in the urge to gamble during exposure to multiple sessions. The urge to
gamble was reduced after repeated exposure to two cues: playing a casino game and discussing gambling with a colleague. The results revealed signicant differences across sessions in the subjective urge
elicited by playing a casino game (F(3.06, 33.64) = 3.05, p = .04).
Post hoc analysis conrmed that scores obtained during sessions 2, 3,
4, and 5 were lower than those at baseline. The level of the urges elicited
by the cue involving discussing gambling with a colleague also differed
across sessions (F(2.44, 26.79) = 3.36, p = .04). The mean urge reported in sessions 3 and 5 was lower than those reported at baseline and
that the urge reported in session 5 was lower than those reported in sessions 2 and 4. Consistent with the results of Experiment 1, psychophysiological measures did not signicantly change across sessions.
4. Discussion and conclusion
To our knowledge, this is the rst study to evaluate the effect of CET
on the urge to gamble using VR system with a design including multiple

C.-B. Park et al. / Addictive Behaviors 41 (2015) 6164

63

Fig. 1. Snapshots of the restful video and 5 casino scenes. Participants watched a 3-min relaxation video to relieve residual tension. While watching the relaxation video, participants were
asked to maintain abdominal breathing under the direction of the research coordinator. Then, participants were exposed to a training environment in which they received instructions
about how to move and interact in the virtual world. This helped them get used to interacting with the virtual environment as well as learn how to input commands. Then, participants
were exposed to each of ve casino scenes: a) navigating the casino environment, b) choosing the amount of chips exchanged, c) witnessing a jackpot scene, d) playing a casino game, and
e) discussing gambling with a colleague. The ve scenes were selected based on clinical interviews with patients with gambling problems and discussion with an experienced addiction
specialist.

independent sessions. The main goal of Experiment 1 was to assess the

feasibility and effectiveness of several virtual environments with specific casino-related cues that were developed by the researchers to elicit
craving in social gamblers. In Experiment 2, the main purpose was to assess changes in urges related to casino gambling associated with
repeated exposure and relaxation training.
The VR casino environment in Experiment 1 was able to evoke a
signicant urge to gamble, which supports the previous literature regarding the use of VR as an approach to exposure (Bouchard, Ct, &
Richard, 2006). The previous studies highlighted the relevance of an
exposure context possessing diversied cues that were adapted to

the population being exposed (Conklin & Tiffany, 2002; Symes &
Nicki, 1997). VR enables such adjustments and makes it possible to
recreate the complexity of a gambling environment and its numerous
associated stimuli while also controlling these stimuli (Giroux et al.,
2013). The participants' urge to gamble was the strongest when they
were exposed to the scene that involved actually playing a casino
game. This nding is consistent with a previous research showing that
an individual's movements within an environment reinforced the
sense that they were actually present, contributing to the realism of
the experience and the intensity of their reactions (Wiederhold &
Wiederhold, 2005).

Table 1
Changes in gambling related variables on Experiments 1 and 2.
Experiment 1 a
VAS
(M
SC
(M
EMG
(M
HR
(M

F statistic Post-hoc

12.92 15.14 13.75 17.47 30.83 22.85 36.67 23.68 37.67 23.72 43.33 28.87 35.83 31.25 20.83 24.01 8.19

a b c, d, e, f, g

SD)
3.13

12.28 19.43 13.36 20.88 14.75 19.68 14.83 22.00 19.35 30.15 18.54 30.34 14.91 28.29 15.99 26.09

.40

88.78 30.99 71.07 9.92

.98

0.66 0.34

0.68 0.44

0.75 0.47

0.77 0.47

0.75 0.45

0.77 0.48

0.76 0.44

0.79 0.55

SD)
SD)
71.64 7.23

70.95 13.61 67.28 14.28 68.51 8.95

72.16 8.57

72.97 8.23

SD)

Experiment 2
VAS (M SD)

Session 1

Session 2

Session 3

Session 4

Session 5

Session 6

F statistic

Post-hoc

a
b
c
d
e
f
g

12.92
13.75
30.83
36.67
37.67
43.33
35.83

10.42
10.83
25.00
28.75
27.08
27.08
32.92

12.08
10.83
26.25
18.75
18.33
25.25
18.75

11.67
10.83
26.25
29.58
23.33
23.33
24.58

8.33
7.92
19.58
22.50
26.67
19.83
12.92

7.50
6.25
19.58
22.08
27.50
30.58
21.67

.65
.89
1.09
2.35
1.56
3.05
3.36

20.83 24.01

Sessions 1 N 2, 3, 4, 5
Sessions 1 N 3, 5;
sessions 2 N 5; sessions 4 N 5

15.14
17.47
22.85
23.68
23.72
28.87
31.25

16.85
15.50
28.76
31.20
23.01
20.94
32.44

15.00 18.22

19.24
20.76
23.85
19.20
20.49
23.93
22.78

8.33 13.54

21.98
21.83
28.37
28.24
29.57
26.91
28.72

13.33 20.49

14.67
12.70
26.32
26.59
29.95
27.89
18.27

9.00 15.56

13.57
11.51
19.59
20.94
23.88
27.38
24.71

9.58 16.02

2.24

Note: F statistics were calculated based on Huynh-Feldt Epsilon correction; post-hoc comparison-LSD; a no exposure, b restful video, c navigating the casino environment,
d choosing the amount of chips exchanged, e witnessing a jackpot scene, f playing a casino game, g discussing gambling with a colleague, h restful video; VAS visual
analogue scale, SC skin conductance, EMG electromyography, HR heart rate; session 1 = experiment 1 (baseline).
p b .05.
p b .01.

64

C.-B. Park et al. / Addictive Behaviors 41 (2015) 6164

Experiment 2 showed that repeated exposure signicantly reduced

the subjective urge to gamble, particularly in response to the scene
that had elicited the strongest urge to gamble in Experiment 1, which
involving playing a casino game. A signicant reduction in the urge to
gamble was also observed for the scene involving discussion with a colleague. However, further consideration of the number of sessions included in the experiment is required. As shown in Table 1, the urge to
gamble decreased continuously as a function of repeated exposure to
a scene depicting playing casino a game, but this trend was interrupted
by a slight and insignicant increase in the urge to gamble during the
last session. A similar pattern was observed for the scene depicting a
discussion with a colleague, suggesting that there may be an optimal
number of sessions that elicits the best therapeutic effect. Additional
research is needed to explore this issue.
It should be noted that no changes in psychophysiological variables
were observed in either experiment. One possible explanation for
this nding is that the participants in this study were all recreational
rather than pathological gamblers. Additionally, the results of previous
studies have been inconsistent with regard to psychophysiological
responses (Choi et al., 2011; Garca-Rodrguez, Pericot-Valverde,
Gutirrez-Maldonado, Ferrer-Garca, & Secades-Villa, 2012). Additional
research is needed to enable a consistent and reliable interpretation of
these results.
VR-based treatment may greatly increase the impact of an intervention. However, interventions must be delivered by specially trained professionals. In this study, the authors particularly emphasized abdominal
breathing. During the session, a coordinator who received professional
training in abdominal breathing was positioned next to the participants
to ensure that the participants maintained the relaxed state immediately before and after exposure. We assume that this contributed to maximizing reciprocal inhibition, which is a key mechanism underpinning
the effectiveness of CET and training regarding coping strategies.
Although this study produced several meaningful ndings, several
limitations should also be mentioned. First, the participants were recreational gamblers. Therefore, future research is needed to assess the effectiveness of CET with larger clinical samples. Second, no follow-up
assessment was conducted to evaluate the long-term effect of CET on
urges related to casino gambling. The long-term effects of this treatment
should be explored in future research. Third, only male participants
were included in this study. Cue reactivity in response to situations
designed to elicit craving may differ between men and women. Future
research should examine sex differences in cue reactivity and therapy
outcomes.
Despite these limitations, the current study was preliminary in nature and its main purpose was to test the feasibility and effectiveness
of a VR casino environment and to determine if the objective psychophysiological responses and subjective cravings related to gambling
would be reduced after repeated exposure to VR cues via a wall projector system. Our study demonstrated that VR CET combined with relaxation training can reduce recreational gamblers' urges and that this is
an efcient intervention for the treatment of PG.

Role of funding sources

This work was supported by a grant from the Korea Healthcare Technology R&D
Project of the Ministry for Health and Welfare, Republic of Korea (HI12C-0113) and by
the Seoul National University Hospital Research Fund (0420110980).
Contributors
Jung-Seok Choi designed the study and wrote the grant. Jun-Young Lee, Hee Yeon
Jung, and Bo Kyung Sohn provided summaries of a previous research and supervised
the development of the virtual environments and the data collection. Su Mi Park and
Chan-Bin Park collected and analyzed the data and wrote the rst draft of the manuscript.
Chan-Bin Park wrote the nal version of the manuscript. All authors contributed to and
have approved the nal manuscript.
Conicts of interest
All the authors declare that they have no conicts of interest.
Acknowledgments
The authors would like to thank Duke Jung at FNI Co., Ltd. for technological support in
the production of the virtual reality content.

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