Information is not enough: a critical perspective on responsible gambling policies to gambling disorder prevention

doi:10.21203/rs.3.rs-4353966/v1

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Information is not enough: a critical perspective on responsible gambling policies to gambling disorder prevention

https://doi.org/10.21203/rs.3.rs-4353966/v1

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Multiple governments and other stakeholders in countries where online gambling has been legalized have implemented responsible gambling policies. Based on theoretical and experimental evidence, this study showed that the information used to implement responsible gambling policies is not sufficient to prevent the emergence of pathological gambling disorder in society. This is because the information provided is necessary, but it is not adequate for modifying gambling habits or preventing addiction. The principal clinical symptoms of gambling disorder are excessive gambling and difficulty in controlling one's gambling.

Objective: the objective of this study was to analyze the effect of a dynamic personal message about the consequences of gambling, specifically, the effectiveness of pop-up messages stating the percentage of money lost in a virtual slot machine.

Method. In this study, 40 gamblers were observed during online gambling. The independent variable was information about their gambling losses provided via pop-up messages.

Results. The main result of the study was that the display of responsible gambling information was associated with no changes in gambling behavior.

Discussion. The study presented in this article and the initial theoretical discussion together reveal that the main strategy used to promote responsible gambling, which is to provide truthful information about gambling and its consequences, is not sufficient to prevent excessive gambling and, therefore, gambling addiction in society, or to make people stop gambling, despite their losses. To prevent excessive gambling and, therefore, gambling disorder in society, gambling policies that limit gamblers’ losses must be implemented.

gambling disorder

responsible gambling

gambling disorder prevention

pop-up messages

ethical gambling

Pathological gambling was initially classified by the ICD-9 [1] and the DSM-III [2] as a mental disorder. More recently, both the DSM-5 [3, 4] and ICD-11 [5] introduced conceptual changes to this definition, and pathological gambling is now included in the same diagnostic category as substance-related disorders, reflecting arguments that have long been proposed for considering pathological gambling an addictive disorder [6, 7]. Gambling addiction is a mental disorder that, in addition to engendering social, family, and legal consequences, is often highly comorbid with other mental illnesses and with substance abuse [8]. Given that gambling disorder is an addictive disease characterized by excessive gambling, implementation of preventive actions is essential to prevent gambling addiction in society.

Responsible gambling [9, 10] is a concept that mediates the idea that gambling can be harmful to some gamblers, and it assumes that governments and companies can mitigate the problems caused by gambling and promote appropriate patterns of behavior. A responsible gambling program rests upon two main principles, according to the Reno Model [10]: a) the ultimate decision of whether to gamble resides with the individual and represents a choice; and b) to make this decision, individuals must have the opportunity to be informed. Therefore, numerous regulations that promote responsible gambling focus on providing informative messages. For example, the Code of Conduct on Responsible Online Gambling Advertising of the European Gaming and Betting Association states that, “Wherever possible, responsible gambling messages should be included in all gambling marketing” [11]. However, there are theoretical considerations indicating that information alone is not sufficient to prevent gambling disorder.

According to the DSM-5-TR, “Gambling behaviors activate reward systems similar to those activated by drugs of abuse and produce some behavioral symptoms that appear comparable to those produced by the substance use disorders” [4]. The main criteria for the diagnosis of gambling disorder include tolerance (a need to gamble with increasing amounts of money to achieve the desired excitement); 'chasing' (after losing money, a return another day to 'get even'); control impairment (repeated unsuccessful efforts to control or stop gambling); gambling when distressed (helpless, guilty, anxious, or depressed); and emotional perturbation when gambling is interrupted. Importantly, most of these clinical criteria for gambling disorder induce excessive gambling.

However, in societies in which gambling is allowed, it is not only a game that increases betting behavior; it is also a major economic activity. Nevertheless, it is an unusual economic activity. First, the profits of gambling companies are the losses of their customers. In terms of game theory [12], gambling is an example of a zero-sum game, a non-cooperative game in which one player’s wins equal the other player’s losses, resulting in a net benefit of zero; and second, all forms of gambling are designed to always favor gambling companies. Therefore, the more money spent on gambling, the greater the probability that the companies managing the games will win.

In other words, gambling is designed to induce excessive gambling because that behavioral pattern is the most profitable for gambling companies. However, excessive gambling harms the gambler and the risk of a gambling disorder is enhanced. Pathological gamblers account for 15–65% of gambling company in comes [13, 14, 15]. In a capitalist society, it is naive to think that companies will sacrifice profitability to prevent gambling addiction.

The main responsible gambling strategy that has been implemented in most countries is the provision of information on gambling risks; other, possibly more effective, strategies [16, 17] have not yet been made mandatory [18]. Recommendations on web pages and brochures on gambling room counters are static in nature; they do not effectively influence gambling behavior. Personalized feedback is also not unequivocally effective; a recent literature review found conflicting results for the effects of personalized feedback on spending and symptoms [19]. Many studies have found that dynamic messages were more effective than static messages, and that messages encouraging self-appraisal had significantly greater effects on self-reported thoughts and behaviors during gambling [20, 21, 22]. Pop-up messages that involve cognitive tasks can interrupt dissociation during game play [23]. However, the direction of the impact depends on the size and design of messages [24, 25]. Thus, both message content and how the message is conveyed play critical roles in affecting gambler behavior, leading to beneficial or harmful results [26].

The introduction of breaks in play is a responsible gambling strategy that is intended to bring the player's attention to losses and motivate him/her to modify or cease play. Such breaks should be accompanied by self-appraisal messages; otherwise, breaks in play may be counterproductive, enhancing urges and the craving to continue [27].

One of the best-known strategies for providing self-appraisal information is to provide pop-up messages that help guide the gambler to play responsibly [28, 29, 8]. However, warning signs that are designed only to inform players when they have been playing for a certain continuous period of time are ineffective because of the difficulty faced, until now, of accurately tracking individual gambling play. It seems that an effective strategy might be for the message to include information on the gambler’s real losses [16] and to be personalized according to each person’s gambling behavior [30] .Therefore, the objective of this study was to analyze the effect of a dynamic personal message about the consequences of gambling, specifically, the effectiveness of pop-up messages stating the percentage of money lost in a virtual slot machine.

Participants. A total of 24 gamblers (10 women and 14 men) aged 18 to 24 years were recruited from gambling venues after they had completed a survey about their gambling habits and associated problems.

Procedure. Participants arrived at the laboratory and were informed that the study involved assessing gambling behavior and that they would gamble on an online slot machine. Participants were given a total of 30 Euros to gamble. The screen displayed was identical to an online slot machine and the results were given in the same format. The cost of each game was 0.50 Euros, and the possible payouts were 0.5, 1, 2, 3, 5, 10 and 30 Euros. The outcome of online spins was pre-programmed so that all participants experienced the same sequence of wins and losses.

We used two different experimental conditions. In the pop-up condition, participants were informed via a pop-up message when they had lost one-third or two-thirds of the money that they had received (10 and 20 Euros, respectively). The messages were: 'You have lost one- third/two-thirds of the money given to you. You must wait a minute to continue playing.' The control group did not receive any pop-up messages, nor did they stop playing. Participants were randomly assigned to one of the two groups.

Independent variables. There were two independent variables, each with two levels: gambling loss information imparted by pop-up messages (informed group vs. not-informed group); and gamblers who met one or more of the gambling-disorder criteria of DSM-5 vs. players who did not meet any gambling disorder criteria

Dependent variable. Number of bets placed.

Instruments. NORC DSM-IV Screen for Gambling Problems, NODS (Gerstein et al., 1999). A 17-item yes/no scale that aims to diagnose pathological gambling according to the diagnostic criteria of the DSM-IV-TR. It was adapted to the current DSM-5 criteria. The range of the scale scores is 0–9.

Hypothesis

• Hypothesis 1: Gamblers who received information about losses would place fewer bets than those who did not receive such information.

• Hypothesis 2: At-risk gamblers (those meeting one or more gambling disorder criteria, measured using NODS) would bet more than those who met none of the pathological gambling criteria.

Table 1 shows the number of bets placed by gamblers in each of the two conditions (with pop-up messages versus without pop-up messages) and for each group of gamblers (at-risk gamblers and non-risk gamblers).

Table 1

Number of bets placed (mean and standard deviation)
	Without pop-up messages	With pop-up messages
At-risk gambler	42.50 (9.73)	47.43 (11.41)
Gambler not at risk	39.67 (6.15)	40.80 (10.33)

The results obtained were the following:

No statistically significant differences were found in the number of bets made by gamblers in the two experimental conditions (with pop-up messages vs. without pop-up messages).
No statistically significant differences were obtained between at-risk gamblers and non-risk gamblers in the number of bets placed.
No statistically significant differences were found in the number of bets placed taking into account the interaction between the two independent variables (pop-up messages and gamblers at risk).

Therefore, the fact that there are no significant differences in any condition or in the interaction between the independent variables means that neither of the two hypotheses has been confirmed.

As Rebecca Cassidy noted, during the last decades of the 20th century, gambling (in the UK) was transformed “from an activity that was tolerated, to a business to be encouraged” [31, p. 21]. This meant that gambling legislation “was domesticated,” and gambling policies were primarily aimed at promoting business, despite general agreement that gambling constituted a public health problem [32]. The adjustment of gambling legislation to promote gambling rather than to prevent the problems caused by its excessive use is a phenomenon that has spread in many countries, especially since the appearance of online gambling, at least in the case of Spain [33].

Governments and companies have argued for responsible gambling policies as a requirement for the promotion of gambling as a business activity. The main postulate of the responsible gambling model is that people should have truthful information about how gambling works and its consequences, as well as its effect on gamblers’ behavior, so that they can decide rationally whether to gamble [9]. Based on this postulate, the gambling industry and governments have developed strategies to provide information about gambling and gamblers’ behavior that is intended to reduce the associated risk. This is the basis of responsible gambling policies, which focus on individual responsibility, minimizing the duty of care owed by governments and the gambling industry [34]. However, there has been a substantial increase in spending on online gambling in Spain, despite the information on responsible gambling provided by gambling companies [35]. The responsibility for responsible gambling should not lie with the gamblers but, rather, should be placed on the administration that regulates gambling [36] and the operating companies [37].

Nevertheless, while responsible gambling strategies based on providing information are necessary, they are not sufficient to prevent gambling addiction in society. In the absence of more effective measures, as setting spending limits [38, 39] information and education campaigns are ineffective in preventing the harms of gambling at the population level.

The main conclusion of this study is that accurate information about the consequences of gambling (losing one-third to two-thirds of the money spent in gambling), accompanied by sufficient time to reflect on these consequences, had no effect on the number of bets placed by gamblers in an online slot machine. In brief, this information about gambling and the associated risks could not prevent gambling behavior and, consequently, gambling disorder.

These results indicate that truthful information is necessary, but not sufficient to prevent either excessive gambling or gambling disorder in society. Information should always be accompanied by regulatory measures based on the principles of learning psychology applied to social contexts. In the case of gambling, there are, at least, three additional features that explain why the information is insufficient to prevent gambling addiction.

First, gambling is potentially addictive [4]. This means that regardless of the information provided, exposure to gambling and the consequences thereof will result in the need to gamble. Therefore, there will be some people who will play repeat edly and will experience problems with gambling.

Second, most of the diagnostic criteria for a gambling disorder (tolerance, withdrawal syndrome, 'chasing', an inability to control gambling) encourage excessive gambling, especially by pathological gamblers [40]. Such gamblers recognize the risks of gambling as they have already suffered first-hand. Many pathological gamblers want to stop gambling, but they cannot.

Third, gambling companies also encourage excessive gambling. Considering that the expected value of all games is in the companies’ favor, the more a player gambles, the more likely he/she is to lose. In market economies, gambling companies prioritize profits (the money that gamblers lose) by means of gambling rules and conditions that always favor the companies. It is naive to suggest that such companies (many of which are transnational corporations based in tax havens) are concerned about anything other than their profit (money from gamblers). Thus, the most profitable clients are the pathological or problematic gamblers [13, 14, 15].

Thus, from a public health perspective, gambling acts like a virus [41], as its structural characteristics and commercial endorsements favor increased gambling behavior in society generally, leading to adverse health consequences.

These findings have been demonstrated in Spain. In Spain, online gambling was legalized in 2011; the government demanded that online gambling companies develop a responsible gambling strategy based, principally, on notices about the risks of gambling and sensible recommendations; this strategy has not worked. Since the legalization of online gambling, gambling spending has grown exponentially and currently exceeds the combined spending on all traditional games (e.g., casinos, machines, lotteries, and bingos) [35]. Within 3 years of its legalization, online gambling has become the second leading cause of gambling addiction in patients undergoing treatment for gambling disorder, and the leading cause in people under 26 years of age [33]. Among school-going individuals aged 15–19 years, gambling addiction has reached epidemic levels. Minors have a higher prevalence of gambling than the general population [18] despite the recommendations and suggestions on all online gambling web pages. Although the government has established a Responsible Gambling Advisory Council, the gambling companies offer awards for gambling skill and organize conferences and symposia, which are all for show, because no evidence-based procedure preventing gambling addiction has been implemented.

Responsible gambling policies should feature strategies that allow gamblers to make appropriate decisions. However, information that gamblers should consider is usually offered only on web pages or in brochures placed on the information counters of gambling rooms. Some of the most common recommendations are a) Play in moderation as a means of entertainment; b) Decide how much money you can lose and do not exceed this figure; c) Do not play to recover losses; d) Do not play to avoid boredom or overcome discomfort; and e) Do not drink alcohol while you play. These are the responsible gambling strategies determined by gambling companies and required by the Spanish government. The recommendations are logical, but very difficult to implement, especially if they are only recommendations printed in a brochure or hidden on a web page. Such recommendations are not in line with the research evidence on effective message content. A gambler does not read brochures prior to playing and does not search gambling websites for information on how to gamble responsibly. Such recommendations are much less effective than the marketing and advertising strategies used to induce gambling. Gambling companies meet the responsible gambling standards, but this has not prevented the growth of pathological gambling among adolescents. On the contrary, a new public health problem has been generated [18].

Pop-up messages are considered one of the most promising responsible gambling techniques, but only if they dynamically affect player behavior [21, 22]. However, in this study, dynamic pop-up messages describing losses did not significantly reduce the number of plays made by players who did or did not fulfill at least one of the nine DSM-5-TR pathological gambling criteria. Clearly, in this study, the pop-up messages that reported losses did not reduce betting. Furthermore, no differences were found between at-risk gamblers and gamblers who did not meet any pathological gambling criteria. Thus, information alone cannot reduce gambling behavior in a real setting. The numbers of bets placed by gamblers meeting 1–3 criteria of a gambling disorder and by problem-free gamblers did not differ. It seems that the structural characteristics of online gambling encourage repeated behavior that overrides information on the negative effects of gambling [42].

In conclusion, to prevent gambling addiction, measures other than the provision of truthful information are required. The main problem with responsible gambling models is that they consider gamblers responsible for their disorder, while placing little or no emphasis on harm-inducing gambling policies [43]. The focus of attention should be not on the patient (that is, the gambler) but on the cause of the addiction (that is, the gambling companies). Therefore, health policies should move beyond the current responsible gambling model [34] and, instead, regulate gambling according to the principles of ethical gambling [36], there by applying moral limits to the market [44]. Anything less is merely show.

Few experiences are available from other countries, such as New Zealand, where the government recognizes gambling as a public health issue and has developed an integrated problematic gambling strategy focused on public health, which includes preventing and minimizing the harm from gambling [45]. In other countries, such as Sweden and the Netherlands, a “duty of care” policy has been included in the legislation. Despite this, the content of these policies is focused more on monitoring players than products [46].

In Spain, daily and monthly limits have been placed on the amount of money that can be bet, which is a substantial improvement over the current regulations, which actually promote online gambling. In total, 83 online gambling websites are authorized to operate in Spain, many of which are run by the main transnational gambling companies. Players can switch between websites and spend huge amounts of money.

To prevent players from exceeding the legal limits by betting on multiple websites, the websites can be forced to operate on a single state-controlled platform. This solution has been proposed by the Parliament of Uruguay as a potential online gambling law and can be an effective method to prevent gambling disorder.

Another solution has been proposed by the ethical gambling model [36] in the form of a personal gambling smart card (PGSD) issued by the government, which would be mandatory for all types of electronic gambling (online and EGMs). The PGSD would record all gambling wins and losses with the aim of preventing large daily, weekly, or monthly losses by blocking gambling for the rest of the day, week, or month when the gambler reaches a limit previously established by the government.

Other strategies designed to prevent or minimize gambling-related problems should also focus on the structural characteristics of gambling in addition to the gamblers [47, 48]. Some of the structural characteristics include restricting gambling speed [49], increasing the time interval between the bet and outcome [50], reducing the maximum bet size [45], diminishing the percentage of win, or reducing the frequency of “near-miss” outcomes on electronic gaming machines [51]. Studies have found that damage minimization strategies that take into account cultural, regional, and personal factors are effective [52].

This study has certain limitations. The study participants played with the money that they had been provided. It is unclear whether similar results would be obtained if the players played with their own money or had self-imposed spending limits.

Author Contributions: LC-O and MCh have participated in all stages of the study: conceptualization, methodology, data analysis and discussion of the results. AL-B has participated in the analysis of the results

Funding: In the last three years, the authors have received funding for other projects on gambling addiction from the Health Department of Mapfre Foundation and the Youth Council of the Government of Valencia.

The authors declare that they have not received funding from gambling companies.

Institutional Review Board Statement: This study is in accordance with the ethical standards of the Spanish government and with the 1964 Helsinki Declaration and its later amendments. All data are anonymous and are in accordance with Law 3/2018, on the protection of personal data and guarantee of digital rights.

This study was approved by the Ethics Committee of University of Valencia for studies involving humans (02/02/2017. Register: H1482079199937).

Informed Consent Statement: All participants signed an informed consent form in which they voluntarily agreed to participate in the research. No personal data was collected in the database used for the analyses.

Data availability: The data is not available in any public database.

Conflicts of Interest: The authors declare that they have no conflicts of interest with any gambling company. The authors subscribe to the Auckland Code of Ethics for gambling researchers

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No competing interests reported.

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Information is not enough: a critical perspective on responsible gambling policies to gambling disorder prevention

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