Preventing gambling-related problems

2010-06-10

Preventing gambling-related problems has been one of the target areas of Swedish public health policy since 1999. This endeavour is just as current today when access to gambling for money is on the rise and the games are taking on new shapes. This report comprises both a knowledge survey of prevention efforts against gambling problems and a systematic literature review based on searches for reviewed articles in various scientific research databases.

The systematic review surveys the scientific evidence for various prevention methods with regard to gambling problems. The knowledge survey provides a background that puts the systematic literature survey in a context. Together, they can hopefully contribute to better conditions for prevention work.

The report provides an overall description of how gambling research has gone
from viewing gambling dependence as a purely medical diagnosis to viewing gambling problems as a continuum. Consequently, gambling becomes of interest in itself, not only “pathological gambling”. The report also presents studies that indicate that games not only affect the individual’s health and personal finances, but gambling may also be significant to social capital, criminality and quality of life in society at large.

A public health perspective of gambling and gambling problems helps us put
gambling in an economic, social and cultural context. Promoting public health primarily involves focusing on epidemiological factors and groups in society instead of the health of single individuals. This does not conflict with the fact that we need good, evidence-based care and treatment. The book discusses important public health concepts and their significance in the field of gambling, and believes that the perspective also means that we should work to even out inequalities in health and that there are strong reasons to include an ethical perspective in public health work.

When we plan measures, it is important to take fundamental ethical perspectives
into account, such as principles of self-determination, care and equity. What causes problems and what increases or decreases the risk of developing problems, referred to as risk and protective factors, are naturally also prerequisites of the prevention efforts. The report notes that risk and protective factors exist on several levels: with the individual him or herself, in the family and immediate surroundings, and in society in general. In international research, there is evidence that we should work on all levels. Risk factors for gambling can be both direct (concern the gambling behaviour) and indirect (concern the gambler’s socioeconomic conditions, migration status, gender, age, mental health, etc.).

Risk and protective factors are discussed both in general and based on what we know of the factors in gambling problems and gambling dependence. The significance of accessibility, inequality, marketing and social stress (dislocation) as risk factors are discussed in particular. Among other theories, the report brings up the biopsychosocial model, which is a model for understanding risk and protective factors of gambling problems.

Theories of capital (social, cultural, economic and symbolic) can also help
us understand people’s various types of vulnerability to risk and the function of
gambling in people’s lives.

The report discusses similarities between gambling problems and other forms of
dependence, mainly alcohol. If there are similarities, the gambling prevention field can find inspiration and test models from alcohol and drug research. Similarities between gambling and other forms of dependence discussed by the report include risk groups, risk and protective factors, how society organises accessibility and supervision, how consumption affects the brain’s reward system and how we can work preventatively and what treatment methods appear to be effective.

A great deal of the prevention work is directed at young people and schools.
The report discusses how drug education in schools has developed from having
been characterised by both scaremongering and pure information efforts to the
widespread belief today that greatest potential of schools lies in strengthening students’ protective factors: preventing truancy, improving the school environment and ensuring that students get on well and complete school. Alcohol, narcotics and tobacco education may nonetheless be relevant, but does not automatically lead to behavioural changes.

Prevention models discussed today in the alcohol and drug area, which are briefly
presented in this report, include the Health Belief Model, the theory of reasoned
action and planned behaviour, the stages of change model, social learning theory,
social planning, the diffusion of innovation theory, the harm reduction model and
ecological theories. The role of health communication in prevention work is also
discussed.

The systematic searches resulted in 38 approved studies, which were divided up
into three different areas:

• Accessibility and legislation. Policy level measures that may concern issues of
  accessibility and other legislative issues.
• Gambling environment and game design. This area concerns what is often referred to as responsible gambling measures, consumer protection and safe products.
• Educational and information efforts that affect the gambler’s or the surroundings’ attitudes to gambling, as well as knowledge and awareness of gambling and gambling problems. The review concludes that more knowledge is needed in all areas.

The studies concerning education and information often lack follow-ups over an extended period of time and several only measure differences in attitudes and knowledge. The connection between knowledge and attitudes on one hand and gambling behaviour and gambling problems on the other has not been adequately studied. Many of the studies concerning education and information are based on small groups of 100–300 participants and the analysis methods are not clearly described. None of the 38 studies come from Sweden. Few come from the Nordic countries or even from Europe. Studies from Australia, the U.S., New Zealand and, above all, Canada are dominant in gambling research, and the extent to which the results can be transferred to Swedish conditions is uncertain.

The report discusses a number of different measures in the various areas. Some
of the main results in the literature review confirm what the alcohol, narcotics and
tobacco area has shown. For example, legislative efforts and more structural measures such as taxation and reduced accessibility have a considerable preventive effect.

The results show adequate certainty that reductions in access to gambling machines also reduces gambling and gambling problems, on condition that it involves significant reductions in access. However, this connection is not entirely simple, linear or clear cut, and we have to take local conditions in society into account.

The report finds no scientific evidence that information and educational measures
directed at students affects youth gambling or gambling problems, which is also in line with the findings of other areas of dependence research. However, we cannot say with adequate certainty that students’ knowledge of gambling increases through information efforts in schools. In terms of general information campaigns,
the review does not find that they have any effect on people’s behaviour or knowledge.

However, there is only one study with a small number of participants, meaning
that the results should be interpreted with caution.

With regard to efforts in the gambling environment and the actual gambling, the
report concludes that there is some evidence that “bet meters” that show how much money a person has bet can help people control their gambling, especially problem gamblers. Gambling also appears to be affected by whether we play for cash or credits, in other words virtual money. The review found some evidence that gamblers lose larger sums of money if they are not holding the money in hand, since credits appear to be perceived as less “real”. This may be of significance to games on the Internet, for instance. There is also adequate certainty that warning messages can increase knowledge among gamblers, but as with other informational measures, it is unclear how it affects gambling and gambling problems. The review also found with adequate certainty that a “close winning” design of around 30 per cent of the gambling rounds increases gambling.

The review’s results also find adequate certainty that efforts such as voluntary disbarment from casinos and educational programs for resellers of games and casino personnel yield results. The shape of the gambling environment, such as lighting, sounds and design, are also of significance to gambling. Although how it affects gambling depends on the rest of the surroundings and what groups are studied.

The review also found some evidence that people gamble more if they have already been exposed to (spent time in) the casino gambling environment, particularly if they have seen others win. The ability of gambling environments to create a desire to gamble is something that gambling dependence therapists work with in exposure  sessions. These results provide yet another reason why it is important that there be gambling-free environments, particularly for young people.

The report finds no clear answer to which methods are effective in prevention
work. It is more difficult to determine the effectiveness of measures that are included in more complex contexts than strictly medical contexts because the effect is not only due to the method, but also the group’s social, economic and cultural composition.

The report concludes that gambling is based on complex social actions and
behaviours that are difficult to reduce to simple theories on outcomes and individual risk factors. We should also develop methods and measures that are in line with the concepts of public health work, especially concepts of participation and ethics, as well as the importance of critical thinking and a scientific foundation. Together, we can create a palette of prevention measures that are well thought out and created in a health promotion framework.