Charting a path towards a public health approach for gambling harm prevention

Methodologies and estimates of social costs of gambling: A scoping review

The definition and measurement of social costs has been debated in gambling literature. Predominant framings of gambling have depicted it as a leisure activity without significant costs other than those caused directly by problem gambling. This view has been recently challenged with a public health perspective, adopting a wider definition of social costs that span beyond issues related to treatment and crime. Definitional debates have resulted in highly heterogenous approaches to calculating the social costs of gambling. The aim of this review is, first, to assess the kind of costs that have been included in existing estimates; second, to compare overall estimates of social costs; and third, to compare methodological differences. We conducted a scoping review following the Joanna Briggs Institute guidelines for scoping reviews, using the PRISMA-SCR/P tool. The literature search included both peer reviewed publications and grey literature and was conducted in June 2023 and repeated in March 2024. After screening, 26 references were included in the review. Estimates in the included studies contained direct costs, such as crime and law enforcement, financial counselling, and treatment-related costs. Indirect cost included items such as health and social care, unemployment, and financial cost of divorce. Intangible costs included, for example, quantifications of suicide, emotional distress, and relationship problems. The number of included cost items varied across studies from 5 to 32. We identified seven different methodological approaches to calculating costs. Total estimates using different approaches varied greatly, ranging from 6 to 324,000 million int$ total, with an average of 3,980 int$ per adult and median 449 int$ per adult. We conclude that the high variation in available total estimates is due to differences in number of cost items and methodological approaches. The results highlight the need for consistent international guidelines for calculating the total social cost of gambling.

The General Acceptability and Use of Smartphone App-Delivered Interventions for Gambling in Australia

Smartphones can extend the reach of evidence-based gambling treatment services, yet the general acceptability of app-delivered gambling interventions remains unknown. This study examined the general acceptability and use of app-delivered gambling interventions, and predictors of both, among 173 Australian adults with a lifetime gambling problem (48.5% male, Mage = 46.4 years) recruited from an online panel. Overall, 55.5% of the sample had a positive attitude toward app-delivered gambling interventions, 8.1% had a neutral attitude, and 36.4% had a negative attitude. Furthermore, one in five participants (20.8%) reported using an app-delivered gambling intervention in their lifetime. Four dimensions of acceptability were examined, wherein 78.6% of participants endorsed confidence in the effectiveness of app-delivered gambling interventions and 66.5% perceived anonymity benefits, while 48.6% endorsed scepticism (e.g., potential to increase isolation) and 69.4% perceived technology-related threats (e.g., difficulty learning and applying app-based strategies). Positive predictors of acceptability and use included younger age, rural/regional residence, gambling expenditure, problem gambling severity, gambling harms, and use of professional support. Acceptability did not increase the likelihood of using app-delivered gambling interventions, however, which may suggest a translation gap. The findings support continued investment into the development and evaluation of app-delivered gambling interventions, with a focus on enhancing engagement and uptake. Uptake could be improved by promoting the effectiveness and anonymity of evidence-based app-delivered gambling interventions, particularly among receptive audiences (young people, rural/regional residents, those with greater problem gambling severity), while redressing scepticism and perceived technology-related threats among vulnerable subgroups (those with greater gambling expenditure and gambling-related harm).

Risk and Protective Factors for Gambling Among Youth by origin: Findings from the three waves of cross-sectional Finnish School Health Promotion Study among 238,939 Students

Gambling is a public health problem that can cause many kinds of harm. The aim of this study was to examine youth gambling by origin, and the risk and protective factors associated with it. The data was drawn from the School Health Promotion Study (n = 238,939) conducted in Finland, representative of the 14 to 16-year-old Finnish schoolchildren. Cross-tabulations and multivariate logistic regression were used in assessing the association between origin and weekly gambling. Interaction terms of origin and background variables related to substance use, peer and family relations and leisure time were then calculated to assess inter-group differences. The study showed that foreign-born, migrant origin and youth from mixed families were more likely to gamble weekly compared to youth with Finnish-born parents. The likelihood of gambling was particularly high among foreign-born and migrant-origin youth. Weekly gambling was significantly more common among boys than girls in all studied youth groups, and it was particularly common among foreign-born boys compared to other groups. Substance use was associated with weekly gambling and even more so among foreign-born youth. There were also differences by origin in the strength of association between other background factors and weekly gambling. Foreign-born boys appear to be especially vulnerable to multiple health and social risks including gambling, making them a particularly important group for targeted preventive programs. Preventive efforts are needed to enhance public awareness, boost parental supervision, and limit gambling-related risks. Special attention is needed to prevent migrant-origin boys from developing problems with gambling.

Gambling Harm-Minimisation Tools and Their Impact on Gambling Behaviour: A Review of the Empirical Evidence

The harms accompanying disordered gambling are well documented. Additionally, there is growing attention to the harms that arise from people who gamble heavily but do not meet the criteria for a gambling disorder. Accordingly, there has been an increasing interest in the effectiveness of consumer protection tools for consumers of gambling products. Subsequently, there is a need to properly evaluate the evidence for their effectiveness. This review aimed to conduct a narrative synthesis of empirical studies to identify gaps, weaknesses, and strengths in the existing evidence for the effectiveness of harm minimisation tools available to people who gamble. This review includes studies published between January 2015 to July 2022 and comprises 55 peer-reviewed studies for final synthesis. Findings reveal that while more research is needed to examine the effectiveness of active and passive consumer protection tools, uptake of tools is low in part because users view them as tools for individuals already experiencing gambling harm as opposed to protective tools for all users. Research is needed to determine effective ways of communicating the value of consumer protection tools for gambling.

Harm-to-self from gambling: A national study of Australian adults

Aims

Understanding how gambling harm is distributed is essential to inform effective harm reduction measures. This first national Australian study of gambling harm-to-self examined the extent, distribution, risk factors, and health related quality of life (HRQoL) impacts of this harm.

Methods

A Random Digit Dialling sample of 15,000 Australian adults was weighted to key population variables. Key measures included the Gambling Harms Scale-10 (GHS-10), PGSI, SF-6D, gambling behaviours, and demographics. Analyses included ordinal logistic regression.

Results

Amongst gamblers, 14.7% reported harm on the GHS-10, including 1.9% reporting high-level harm. While high-level harm occurred mainly in the problem gambling group (77.3%), other PGSI groups accounted for most of the more prevalent low (98.5%) and moderate (87.2%) harms reported. Proximal predictors of greater harm were use of online gambling and more frequent gambling on electronic gaming machines (EGMs), race betting sports betting, poker, skin gambling, scratchies, and loot box purchasing. Distal predictors were being younger, male, single, Aboriginal or Torres Strait Islander, and speaking a non-English language at home. At the population level, the greatest aggregate HRQoL impacts were amongst lower-risk gamblers, confirming the results of other studies regarding the 'prevention paradox'.

Conclusions

The distribution of harm across gambler risk groups indicates the need for preventive measures, not just interventions for problem gambling. Reducing harm requires modifying product features that amplify their risk, especially for EGMs, race betting and sports betting that are both inherently risky and widely used. Gambling harm exacerbates health disparities for disadvantaged and vulnerable groups, requiring targeted resources and support.

The Dual Burden of Emerging Adulthood: Assessing Gambling Severity, Gambling-Related Harm, and Mental Health Challenges

Growing concerns over gambling problems across age groups have sparked research in public health and psychology. During emerging adulthood, individuals are more susceptible to mental health problems and more likely to develop gambling problems than in other age groups. This study explored the potential differences between emerging adults and adults aged 30+ in terms of problem gambling severity (PGS), gambling-related harm (GRH), depression and anxiety, and the mediating role of depression and anxiety in the association between age, PGS, and GRH. A representative online sample of 3244 Israelis aged 18 and over was divided into two groups: 740 emerging adults aged 18-29 and 2504 adults aged 30+. Gambling behaviors, the Problem Gambling Severity Index, the Short Gambling Harm Screen, and the Patient Health Questionnaire-4 assessing depression and anxiety were administered. Emerging adults had significantly higher levels of GRH, PGS, and depression-anxiety than their older counterparts, above and beyond gender and education. Depression-anxiety fully mediated the associations between age and gambling-related outcomes. These findings underscore the importance of considering psychological well-being in efforts to address problem gambling and gambling-related harms, especially in emerging adults.

Towards a conceptual framework for the prevention of gambling-related harms: Findings from a scoping review

The global gambling sector has grown significantly over recent years due to liberal deregulation and digital transformation. Likewise, concerns around gambling-related harms-experienced by individuals, their families, their local communities or societies-have also developed, with growing calls that they should be addressed by a public health approach. A public health approach towards gambling-related harms requires a multifaceted strategy, comprising initiatives promoting health protection, harm minimization and health surveillance across different strata of society. However, there is little research exploring how a public health approach to gambling-related harms can learn from similar approaches to other potentially harmful but legal sectors such as the alcohol sector, the tobacco sector, and the high in fat, salt and sugar product sector. Therefore, this paper presents a conceptual framework that was developed following a scoping review of public health approaches towards the above sectors. Specifically, we synthesize strategies from each sector to develop an overarching set of public health goals and strategies which-when interlinked and incorporated with a socio-ecological model-can be deployed by a range of stakeholders, including academics and treatment providers, to minimise gambling-related harms. We demonstrate the significance of the conceptual framework by highlighting its use in mapping initiatives as well as unifying stakeholders towards the minimization of gambling-related harms, and the protection of communities and societies alike.

Availability restrictions and mandatory precommitment in land-based gambling: effects on online substitutes and total consumption in longitudinal sales data

BACKGROUND

Gambling causes important harms in societies. According to the public health approach, the most effective policies to reduce harms target full populations. Availability restrictions and mandatory precommitment are among the most effective measures. However, restrictions on the availability of some gambling products or channels may also be offset by increased consumption in other products. Substitution effects can have negative public health impacts due to differing harm potential across different gambling products. This paper uses longitudinal sales data (2019-2022) from the Finnish gambling monopoly Veikkaus. During the observation period, the availability of gambling was restricted in Finland due to subsequent waves of Covid-19-related restrictions. In addition, the gambling monopoly introduced mandatory precommitment to land-based EGMs. We focus on how these restrictive policy changes impacted the total consumption of gambling and possible substitution effects.

METHODS

The Finnish gambling monopoly provided weekly theoretical loss data per gambling product category and gambling channel (online, land-based) for the period of January 2019 - July 2022 based on a statutory obligation. We analysed the effects of availability restrictions and other public health measures on the consumption of different products using descriptive time series and regression analyses. We compared the sale of land-based products to online equivalents at product category level and included main policy change periods in the models.

RESULTS

Total consumption of gambling declined during 2019-2022 mainly due to reduced land-based electronic gambling machine (EGM) consumption. Declines in land-based EGM sales were not offset by online alternatives or other close substitutes in the long term. However, during the first wave of Covid-19, there was an observable substitution of land-based table games by online alternatives and land-based horse betting and possibly sports betting by online horse betting. Overall, the results also show that Covid-19 functioned as a boost to an already existing trend of increasing digitalisation of gambling.

CONCLUSIONS

The study provides empirical support for the effectiveness of public health-oriented policies in reducing the total consumption of gambling. Availability restrictions and mandatory precommitment are therefore likely to also reduce the burden of harms of gambling to individuals and societies.

Involving lived experience in regional efforts to address gambling-related harms: going beyond 'window dressing' and 'tick box exercises'

BACKGROUND

Lived Experience (LE) involvement has been shown to improve interventions across diverse sectors. Yet LE contributions to public health approaches to address gambling-related harms remain underexplored, despite notable detrimental health and social outcomes linked to gambling. This paper analyses the potential of LE involvement in public health strategy to address gambling-related harms. It focuses on the example of a UK city-region gambling harms reduction intervention that presented multiple opportunities for LE input.

METHODS

Three focus groups and 33 semi-structured interviews were conducted to hear from people with and without LE who were involved in the gambling harms reduction intervention, or who had previous experience of LE-informed efforts for addressing gambling-related harms. People without LE provided reflections on the value and contributions of others' LE to their work. Data analysis combined the Framework Method with themes developed inductively (from people's accounts) and deductively (from the literature, including grey literature).

RESULTS

Four themes were identified: (1) personal journeys to LE involvement; (2) the value added by LE to interventions for addressing gambling-related harms; (3) emotional impacts on people with LE; and (4) collective LE and diverse lived experiences. Two figures outlining LE involvement specific to gambling harms reduction in the UK, where public health efforts aimed at addressing gambling-related harms coexist with industry-funded programmes, are proposed.

CONCLUSIONS

Integrating a range of LE perspectives in a public health approach to gambling harms reduction requires local access to involvement for people with LE via diverse routes that are free from stigma and present people with LE with options in how they can engage and be heard in decision-making, and how they operate in relation to industry influence. Involving LE in gambling harms reduction requires enabling people to develop the affective and critical skills necessary to navigate complex emotional journeys and a challenging commercial and policy environment.

Public health approaches to gambling: a global review of legislative trends

The public health community has called for governments to recognise the harms associated with gambling, and for gambling policies to include population-based harm prevention approaches. This Health Policy explores the translation of this call into global policy action by systematically reviewing legislation of jurisdictions that introduced major gambling legislation change (ie, restricting or extending gambling provision) between Jan 1, 2018, and Dec 31, 2021. We mapped the global availability of legal gambling and changes in its provision, and conducted critical frame analysis on a sample of 33 jurisdictions introducing major policy change to assess the extent to which the protection of health and wellbeing was embedded within legislation. More than 80% of countries worldwide now legally permit gambling. Harmful gambling was recognised as a health and wellbeing issue in most of the analysed jurisdictions, but near-exclusive focus was given to individual-level harms rather than to wider social and economic harms, or harms to others. Most of the proposed prevention measures focused on individual responsibility. Gambling policies worldwide are changing, but addressing gambling as a public health issue is not yet translating into comprehensive policy action across jurisdictions.

Exploring the psychosocial characteristics of women with gambling disorder through a qualitative study

Introduction

Gambling disorder is a behavioral addiction that has been primarily male, but in the last few years, the age of onset has been equated between the sexes. The profile of female gamblers could be different from that of men. Consequently, this study analyzes the testimonies of women with gambling disorder to determine their specific characteristics (gambling motives, gambling preferences, and associated pathologies).

Method

The sample comprises 18 women with gambling disorder aged between 30 and 68. Three discussion groups were held, and a "blind" inductive process was carried out to extract categories. The Atlas.Ti 22.0 program was used to recode and analyze the data.

Results

Results show that women may start gambling due to abuse suffered in childhood, and often family members initiate women into gambling. Likewise, the onset of gambling could be a maladaptive way to manage negative emotions. Also highlighted is the predominance of feelings of social stigmatization, which can be reflected in women's choice of games where they are not visible. Comorbidity with other disorders such as depression, anxiety, bipolar disorder, personality disorders, and the use of other substances are noteworthy.

Discussion

The factors explaining why female gamblers do not seek treatment compared to male gamblers are analyzed. More studies on women's experience with gambling are needed to address the specific characteristics of gambling disorder in women.

Associations Between Heavy Episodic Drinking, Drinking While Gambling, and Risky Gambling

INTRODUCTION

Understanding how patterns of drinking are associated with risky gambling in Australia is needed to inform an effective approach to minimise harm.

METHODS

This cross-sectional questionnaire study reports on 2,704 subsampled participants who completed survey questions about their patterns of drinking. With logistic regressions, we examined whether frequency of heavy episodic drinking (HED) and alcohol use while gambling were associated with risky gambling while controlling for sociodemographic variables.

RESULTS

Occasional HED and monthly HED were associated with any gambling (versus no gambling), but frequent HED was not significantly associated with gambling. The opposite pattern was found when predicting risky gambling. Occasional HED (i.e. less than monthly) was not significantly associated, but a higher frequency of HED (at least weekly) was associated with a higher likelihood of risky gambling. Drinking alcohol while gambling was associated with risky gambling, over and above HED. The combination of HED and use of alcohol while gambling appeared to significantly increase the likelihood of risky gambling.

CONCLUSIONS

The association of HED and alcohol use while gambling with risky gambling highlights the importance of preventing heavy alcohol use among gamblers. The links between these forms of drinking and risky gambling further suggests that individuals who engage in both activities are specifically prone to gambling harm. Policies should therefore discourage alcohol use while gambling for example by prohibiting serving alcohol at reduced prices or to gamblers who show signs of being affected by alcohol and informing individuals of the risks associated with alcohol use while gambling.

Effectiveness of a web-based self-help tool to reduce problem gambling: A randomized controlled trial

Background and Aims

Problem gambling constitutes a public health concern associated with psychopathological comorbidity, substance use, and financial difficulties. Most individuals with gambling problems avoid counseling services due to perceived stigma and their preference for self-reliance. Treatment accessibility could be improved through web-based interventions.

Methods

We recruited 360 individuals with gambling problems and randomized them to a web-based intervention (n = 185) or an active control group consisting of a self-help manual for problem gambling (n = 175). The primary outcome was the number of days of gambling in the last 30 days. Secondary outcomes included money spent in the last 30 days, time gambling in the last 7 days, gambling-related problems, consumption of alcohol and cigarettes, and psychopathological comorbidity measured at posttreatment and 6-month follow-up.

Results

The primary outcome decreased significantly for both groups, with no significant difference between the groups. There were significant group × time interactions according to the Gambling Symptom Assessment Scale (F = 8.83, p <0 .001), the Problem Gambling Severity Index (F = 3.54, p = 0.030), for cigarettes smoked in the last 7 days (F = 26.68, p < 0.001), the Patient Health Questionnaire-9 (F = 19.41, p <0 .001), and the Generalized Anxiety Disorder-7 (F = 41.09, p <0 .001) favoring the intervention group. We experienced an overall high dropout rate (76%).

Conclusions

Win Back Control seems to be an effective low-threshold treatment option for individuals with gambling problems that might otherwise be unapproachable for outpatient treatment services. Nevertheless, the high dropout rate should be considered when interpreting the study results, as they may have introduced a degree of variability.

Examining the Gambling Behavior of University Students: A Cross-Sectional Survey Applying the Multi-Theory Model (MTM) of Health Behavior Change in a Single Institution

Gambling among college students can start as a pastime activity. However, this pastime can lead to problem gambling and pathological gambling. This cross-sectional study aimed to identify and explain the initiation and sustenance of quitting gambling among university students who had participated in gambling during the past month and those who had not using a novel fourth-generation multi-theory model (MTM) of health behavior change. Data were collected from a sample of 1474 university students at a large southwestern university in the U.S. between January 2023 and February 2023, utilizing a validated 39-item survey. The statistical analyses employed in this study encompassed descriptive statistics, independent samples t-tests, and hierarchical regression modeling. Among students who had engaged in gambling in the past month, the constructs of participatory dialogue (β = 0.052; p < 0.05), behavioral confidence (β = 0.073; p < 0.0001), changes in the physical environment (β = 0.040; p = 0.0137), and demographic variables accounted for 27.7% of the variance in the likelihood of initiating the behavior change. Furthermore, the constructs of emotional transformation (β = 0.104; p = 0.0003) and practice for change (β = 0.060; p = 0.0368), and demographic variables accounted for 22.6% of the variance in the likelihood of sustaining quitting gambling behavior. The Multi-Theory Model (MTM) can be employed to design interventions aimed at reducing problem gambling among college students.

Gambling harm prevention and harm reduction in online environments: a call for action

BACKGROUND

Gambling is increasingly offered and consumed in online and mobile environments. The digitalisation of the gambling industry poses new challenges on harm prevention and harm reduction. The digital environment differs from traditional, land-based gambling environments. It increases many risk-factors in gambling, including availability, ease-of-access, but also game characteristics such as speed and intensity. Furthermore, data collected on those gambling in digital environments makes gambling offer increasingly personalised and targeted.

MAIN RESULTS

This paper discusses how harm prevention and harm reduction efforts need to address gambling in online environments. We review existing literature on universal, selective, and indicated harm reduction and harm prevention efforts for online gambling and discuss ways forward. The discussion shows that there are several avenues forward for online gambling harm prevention and reduction at each of the universal, selective, and indicated levels. No measure is likely to be sufficient on its own and multi-modal as well as multi-level interventions are needed. Harm prevention and harm reduction measures online also differ from traditional land-based efforts. Online gambling providers utilise a variety of strategies to enable, market, and personalise their products using data and the wider online ecosystem.

CONCLUSION

We argue that these same tools and channels should also be used for preventive work to better prevent and reduce the public health harms caused by online gambling.

Crisis, What Crisis? The Effect of Economic Crises on Spending on Online and Offline Gambling in Spain: Implications for Preventing Gambling Disorder

(1) Background: In the period between 2008 and 2020, the world experienced two global economic crises that affected people's way of life and well-being: the financial crisis of 2008 and that precipitated by the COVID-19 pandemic. Despite the crises' radically different causes, their consequences for economic activity have been equally dramatic; (2) Methods: This article analyzes the consequences of both crises on gambling spending in Spain and compares traditional (offline) games with more recent online offerings. The data were collected from databases maintained by the Spanish government and gambling companies; (3) Results: The paper offers two main conclusions. The first is that, while traditional (offline) gambling has been significantly affected by economic crises, online gambling has exhibited consistent growth since its legalization. The second is that the measures implemented to resolve the two economic crises differed significantly and thus had different impacts on spending on the various types of gambling; (4) Conclusions: The key conclusion is that purchasing power (measured in terms of GDP) can only explain spending on less addictive gambling games, such as lotteries. However, the availability and accessibility of games are both directly related to spending on games of all types.

Politics of hesitance and the formation of ethical subjects through responsible gambling practices

INTRODUCTION

Instead of harm prevention and risk related to gambling products, responsible gambling discourse emphasizes the importance of voluntary measures. From the point of view of governmentality, the responsible gambling practices produce, rely on, and call forth subjectivities. The aim of the study is to find out what kind of subjects are being produced through the responsible gambling practices of four Nordic state-owned gambling companies. As the companies are state-owned and operate on different types of markets, there are reasons to suspect that the companies could endorse different versions of the figure of responsible gambler. Previous research indicates that responsible gambling practices typically presuppose or aim to produce a self-governing subject making informed choices. Less attention has been given to detailed analyses of the heterogeneous factors contributing to the ethical subject formation. Moreover, there is a growing body of literature indicating, that along with the use of detailed behavioral data (big data), new forms of governmentality, that are highly relevant from the point of view of subject formation, are emerging.

METHODS

The responsible gambling practices are analyzed along Michel Foucault's four aspects of ethics. First, there is ethical substance, the problematic aspect of the self that is taken as the target of the ethical work. Second, the subject needs to have a certain relation to social norms and moral codes. Third, ethical work is needed to mold the problematic aspect of the self. Fourth, the aim of the ethical work is a certain mode of being or relationship to oneself. The analyzed material consists of the annual reports of the companies between 2019 and 2021.

RESULTS AND DISCUSSION

The results show that the figure of subject making informed voluntary choices is deeply embedded in the responsible gambling practices of the companies. The companies entice the gamblers to think about themselves and to act upon themselves as subjects capable of self-control. Hesitancy to intervene characterizes the activities of the companies, even if all the companies collect and use detailed behavioral data. The inclusion of the precarious subject of gambling harm would allow the companies to do much more to prevent gambling harm.

Global prevalence of help-seeking for problem gambling: A systematic review and meta-analysis

BACKGROUND AND AIMS

Multiple studies have examined barriers and facilitators to help-seeking, but the prevalence of help-seeking for problem gambling (PG) is not well established. We aimed to estimate the international prevalence of help-seeking for PG among the general population and among subgroups of people at risk for PG (i.e. low-risk, moderate-risk and PG).

METHODS

Systematic search of grey literature (through gambling repositories, gambling research institutes and Google) and peer-reviewed literature (through ProQuest, PsycINFO, PubMed and Scopus) for gambling prevalence studies that reported on help-seeking for PG. This review adhered to the Preferred Reporting Items for Systematic Review and Meta-Analyses. Studies used representative sampling methods to determine the prevalence of gambling participation and data collection 2010 onward. Twenty-four studies met the inclusion criteria. The main outcome was population prevalence of help-seeking for PG. Help-seeking was defined as any intentional action to change gambling behaviours, including professional services (inclusive of in-person or distance help), non-professional help (e.g. from family and friends) and self-help. Subgroup analyses were conducted to explain variability in help-seeking prevalence estimates.

RESULTS

Measurement of help-seeking was inconsistent across included studies and, overall, there was high risk of bias. We estimated a general population help-seeking prevalence for PG of 0.23% (95% CI, 0.16-0.33). Prevalence estimates were significantly higher in studies assessing lifetime (0.50%; 95% CI, 0.35-0.71) compared with current help-seeking (0.14%; 95% CI, 0.10-0.20, P < 0.001), but there was no evidence of difference in prevalence estimates by gambling participation, region, type of help-seeking, or year of data collection. Compared with people with low-risk gambling (0.27%; 95% CI, 0.07%-1.04%), prevalence estimates were significantly higher in those with moderate-risk (3.73%; 95% CI, 2.07%-6.63%) and problem gambling (20.63%; 95% CI, 12.89%-31.35%, P < 0.001).

CONCLUSIONS

One in 25 moderate-risk gamblers and 1 in 5 people with problem gambling have sought help for problems related to their gambling.

Social Connectedness and Associations with Gambling Risk in New Zealand

Multiple factors are associated with disordered gambling, with some populations having a greater risk for developing disordered gambling than others. The present study, utilising data previously collected for a New Zealand (NZ) national gambling survey, explored the associations of social connectedness and leisure activities with risky gambling behaviour and quality of life. Poorer social connectedness and leisure activities were found to be associated with increased gambling risk and poorer quality of life, respectively. Social connectedness and leisure activities strongly predicted type of gambling activities and quality of life. Furthermore, Māori (NZ's indigenous population) had lower social connectedness and fewer leisure activities, and a greater gambling risk, as well as higher psychological distress, than the NZ European/Other population. These findings indicate that the risk of progressing from recreational gambling to risky gambling is relatively higher for Māori, and that social connectedness and leisure activities could be contributing factors for this increased risk. It is, therefore, important that social connectedness and leisure activities are seriously considered in public health and treatment efforts to reduce gambling harm for vulnerable populations.

Legacy Gambling Harms: What Happens Once the Gambling Stops?

Purpose of Review

Legacy gambling harm refers to adverse consequences that extend past the period where people are actively gambling at harmful levels. These harms can affect the gambler, people close to them and the wider community. This article reviews current research that investigates legacy harms; the types of legacy harm, how long they last and whether evidence suggests these harms are real or instead imagined injuries or reflections on past regrets.

Recent Findings

Legacy harms to individuals can be broadly categorised as including financial, relationship, emotional/psychological, health, culture, work/study and criminal/deviance harms. In addition, legacy harms affect entire communities by drawing funds and social capital away from vulnerable communities, leaving them socially, culturally and materially impoverished. Most legacy harms that accrue to gamblers have a half-life of 4 years, although financial harms last somewhat longer at 5 years. Greater distance in time from a past gambling issue is reliably and positively related to health and well-being indicators, including the Health Utility Index and the Australian Unity Wellbeing Index, which suggests that legacy gambling harms are real and have a lasting impact on well-being, rather than just imagined hardship from prior gambling difficulties.

Summary

These findings suggest programme and policy development to support gamblers in reducing and managing their legacy harms, rather than focusing only on relapse prevention.

Regulating Gambling-Like Video Game Loot Boxes: a Public Health Framework Comparing Industry Self-Regulation, Existing National Legal Approaches, and Other Potential Approaches

Purpose of Review

Loot boxes are gambling-like monetisation mechanics in video games that are purchased for opportunities to obtain randomised in-game rewards. Gambling regulation is increasingly being informed by insights from public health. Despite conceptual similarities between loot boxes and gambling, there is much less international consensus on loot box regulation. Various approaches to regulating loot boxes are reviewed via a public health framework that highlights various trade-offs between individual liberties and harm prevention.

Recent Findings

Many countries have considered regulation, but as yet only a few countries have taken tangible actions. Existing regulatory approaches vary greatly. More restrictively, Belgium has effectively ‘banned’ paid loot boxes and prohibits their sale to both children and adults. In contrast, more liberally, China only requires disclosure of the probabilities of obtaining potential rewards to provide transparency and perhaps help players to make more informed purchasing decisions. Most other countries (e.g., the UK) have adopted a ‘wait-and-watch’ approach by neither regulating loot box sales nor providing any dedicated consumer protection response. Industry self-regulation has also been adopted, although this appears to elicit lower rates of compliance than comparable national legal regulation.

Summary

Many potential public health approaches to loot box regulation, such as expenditure limits or harm-reducing modifications to loot box design (e.g., fairer reward structures), deserve further attention. The compliance and clinical benefits of existing interventions (including varying degrees of regulation, as adopted by different countries, and industry self-regulation) should be further assessed. The current international variation in loot box regulation presents opportunities to compare the merits of different approaches over time.

Gambling-related harms to concerned significant others: A national Australian prevalence study

Background and aims

Gambling-related harm to concerned significant others (CSOs) is an important public health issue since it reduces CSOs' health and wellbeing in numerous life domains. This study aimed to 1) estimate the first national prevalence of CSOs harmed by gambling in Australia; 2) identify the characteristics of CSOs most at risk of harm from another person's gambling; 3) compare the types and number of harms experienced by CSOs based on their relationship to the person who gambles; and 4) compare the number of harms experienced by CSOs by self-identified gender.

Methods

Based on a national CATI survey weighted to population norms, 11,560 respondents reported whether they had been personally and negatively affected by another person's gambling in the past 12 months; and if so, answered detailed questions about the harms experienced from the person's gambling who had harmed them the most.

Results

Past-year prevalence of gambling-related harm to adult Australian CSOs was (6.0%; 95% CI 5.6%-6.5%). CSOs most commonly reported emotional harms, followed by relationship, financial, health and vocational harms, respectively. Former partners reported the most harm, followed by current partners, other family members and non-family members, respectively. Female CSOs were more likely to report more harm and being harmed by a partner or other family member, and male CSOs from a non-family member.

Discussion and conclusions

The findings provide new insights into the wider societal burden of gambling and inform measures aimed at reducing harm to CSOs from gambling and supporting them to seek help.

House-edge information and a volatility warning lead to reduced gambling expenditure: Potential improvements to return-to-player percentages

Cost-of-play information is one public health intervention recommended to help reduce gambling-related harm. In the UK, this information is given on electronic gambling machines in a format known as the "return-to-player", e.g., "This game has an average percentage payout of 90%." However, previous evidence suggests that this information could be improved by equivalently restating it in terms of the "house-edge", e.g., "This game keeps 10% of all money bet on average." A "volatility warning," stating that this information applies only in the statistical long-run, has also been recommended to help gamblers understand cost-of-play information. However, there is no evidence comparing these information provisions' effect on gamblers' behavior. An experiment tested US gamblers'(N = 2433) incentivized behavior in an online slot machine, where this information was manipulated between-participants along with a counter showing the total amount bet. Preregistered analyses showed that participants gambled significantly less when house-edge information or a volatility warning were shown compared to standard return-to-player information, with no effect of the total amount bet counter, and no significant interaction effects. However, these significant findings had small effect sizes, suggesting that a public health approach to gambling should not rely on informational provisions only. Subject to supportive evidence from more ecologically-valid designs such as field studies, these results suggest that improved cost-of-play information could lead to reduced rates of gambling expenditure and therefore benefit a public health approach to gambling.

How many children are exposed to at-risk parental gambling in Australia? Results from a representative national sample

Children of problem gamblers are at risk of harm, however, there are no population level estimates as to how many children are currently exposed to parental problem- and at-risk gambling. The current study analysed data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey, a nationally representative survey, to derive the first ever national estimates of the proportion of problem, moderate, and low risk gamblers (as measured by PGSI) in the Australian parent population. It also reports how many children under 15 years of age in Australia are exposed to parental gambling across the gambling risk categories. The results show that 13.7% of all Australian families with dependent children are currently exposed to some level of gambling risk due to parental gambling, and nearly 4% of families with children are exposed to parental moderate risk or problem gambling. This corresponds to almost 200,000 children each year. The results and approach of this study will guide future examination of child wellbeing in families where parents experience problems with gambling. The results are discussed in the context of public health approaches to familial gambling harm.

Increasing harms for bingo players: digitisation, commercialisation and regulatory inadequacy: a multi-site case study

BACKGROUND

Bingo is often understood as a low-harm form of gambling. This view has been challenged by a growing body of literature identifying gambling harm to bingo players in a range of countries. In this study, we aimed to identify which conditions enabled, facilitated, intensified or mitigated gambling harm for bingo players in three populations in Victoria in the context of corporate, technological and regulatory changes.

METHODS

Our qualitative study investigated experiences of bingo-related gambling harm in three populations in Victoria, Australia where bingo was popular and structural disadvantage common: Indigenous people in the east, Pacific people in the state's north and older people on low or fixed incomes in the capital. Data was generated through interviews with 53 bingo players and 13 stakeholders as well as 12 participant observations of bingo sessions.

RESULTS

We found that while bingo is overwhelmingly positive for many players, a minority of bingo players and their families experience notable harm. Harm was generated through traditional paper-based bingo games, new technologies such as tablet-based bingo and by the widespread tactic of placing bingo sessions in close proximity to harmful electronic gambling machines. Overall, the risk of harm to bingo players appears to be escalating due to commercial, technological and regulatory changes.

CONCLUSIONS

These changes can be better managed by regulators: reforms are needed to safeguard bingo's distinct character as a lower-risk form of gambling at a time when it, and its players, are under threat. Significantly, we found that harm to bingo players is intensified by factors external to gambling such as racialised poverty and adverse life events. Strategies that recognise these factors and grapple with gambling harm to bingo players are needed.

Gamblers' perceptions of responsibility for gambling harm: a critical qualitative inquiry

BACKGROUND

Gambling has traditionally been conceptualised as an issue of addiction and personal responsibility. While there are now clear public health models that recognise that gambling harm is caused by a range of socio-cultural, environmental, commercial and political determinants, government and industry messages about gambling are still largely personal responsibility focused. Given the well-recognised issues associated with personal responsibility paradigms, this study sought to understand how gamblers themselves conceptualised responsibility for gambling harm.

METHODS

A qualitatively led online panel survey was conducted with 363 adult gamblers in New South Wales and Victoria, Australia. Participants were asked to respond to what they thought were the causes of gambling harm, and what could be done to prevent harm. A reflexive thematic analysis was conducted.

RESULTS

Six common tropes were constructed from gamblers' responses: (1) Gambling in moderation; (2) Personal responsibility for rational behaviour; (3) Character flaws; (4) Personal responsibility to seek help; (5) More education is needed; and (6) Governments are responsible for action - but motivation and efficacy are questioned. Gamblers primarily understood gambling harm as being a matter of personal responsibility, and government responsibility was generally seen as limited to providing information to facilitate informed gambling choices.

CONCLUSIONS

This study demonstrates that gamblers' perceptions of gambling harm are similar to the personal responsibility framings and tropes present in industry and government messaging strategies. Refocusing public communication strategies away from 'responsible gambling' messaging, and towards evidence-based approaches, will be an important part of addressing the harms associated with gambling.

Mental Health Over Time and Financial Concerns Predict Change in Online Gambling During COVID-19

This study examined online gambling behavior during COVID-19 land-based gambling restrictions and associations with changes in mental health, impacts on household income due to the pandemic, financially focused motivations, and symptoms of gambling problems. A repeated online survey was administered to adult gamblers in Ontario, Canada. Wave 1 was conducted at the beginning of the first COVID-19 lockdown (April 2020) and wave 2 in August 2020. Respondents (N = 940) completed validated self-report questionnaires related to depression and anxiety, financial motivation, financial impacts due to the pandemic, online gambling behaviors, and problem gambling symptomatology. A cluster analysis identified three subgroups: no online gambling (subgroup 1), engagement in a range of gambling games online and change in gambling involvement (i.e., some increased and some decreased gambling; subgroup 2), and predominantly online lottery play with no change in online gambling (subgroup 3). Respondents who reported increased anxiety and depression symptom severity between the two waves and those who experienced greater symptoms of problem gambling and negative impacts on household income due to COVID-19 were most likely to be found in subgroup 2. Greater financial focus was also noted in this group. Results indicate a link between change in online gambling involvement during COVID-19 and increased mental health problems, elevated problem gambling severity, negative impacts on household income, and a greater financially focused self-concept. These results may help generate novel research questions examining short and long-term effects of the pandemic on online behaviors that inform policy and practice.