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Gambling Harm Minimisation

ABACUS Feedback to the Ministry of Health
regarding
Emerging Trends in National & International Literature.

This summary of research has relevance to the clinical workforce,
it forms part of a regular six monthly report provided by ABACUS to the Ministry.

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Feedback to MOH
Emerging Trends in National & International Literature

Report No. 19 / Period covered:
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Literature:

Young people and gambling survey 2019: A research study among 11-16 year olds in Great Britain - October 2019

Author: IPSOS; Gambling Commission (UK)

https://www.gamblingcommission.gov.uk/PDF/Young-People-Gambling-Report-2019.pdf

Findings:

  • The survey of 124 schools in the UK (ages 11-16; N=2,943) by Ipsos MORI on behalf of the Gambling Commission was to ‘explore young people’s attitudes towards gambling and their participation in different types of gambling attitudes’.
  • The report notes that 11% of participants had gambled over the previous 7 days (compared with 14% the previous year), with boys more likely to gamble (13% vs 7% of girls surveyed), and older children (14-16; 12%) more likely to gamble than younger children (11-13; 9%).
  • Most common gambling was private bets for money (5% of the children surveyed), followed by ‘fruit machines’ (4%) and cards for money (3%). A ‘small but significant increase in online gambling (1% in 2018, up to 3% in 2019) was noted.
  • The Report noted that approximately half of pocket money was spent gambling by the 11% surveyed who gambled.
  • As to risk behaviours over the previous week, gambling at 11% was less than alcohol use (16% of those surveyed drank alcohol over the previous week), but gambling was a higher behaviour than smoking tobacco cigarettes (6%), use of e-cigarettes (7%), or use of illegal drugs (5%).
  • The authors noted that compared with the previous year’s survey and other findings (including the spending of their own money), that there appeared (‘suggested’) a relationship between these ‘harmful activities’.
  • Those who had gambled were more likely to have drunk alcohol (41% compared with all surveyed at 16%), more likely to have taken drugs (21%), or used an e-cigarette (27%).
  • The authors noted that of those who had gambled, their first experience of gambling (23%) was fruit/slot machines (a kind of EGM), and this had been consistent in previous surveys.
  • The non-gamblers mainly explained their reason for not gambling was that it was illegal and they were under-age (56%), while those who did gamble gave their main reason for gambling was that it was fun (55%).
  • There was low interest in the young people in National Lottery (3%, down from 10% in 2011 over the previous 7 days), and this had reduced in participation year by year. However, 13% of 11-15 year olds had played it at some time, with the main version being scratch cards.
  • The authors noted that two-thirds had bought the National Lottery product in the presence of a parent/guardian who in most circumstances (73%) had paid on the young person’s behalf.
  • Online gambling was relatively low (3% in last 7 days), while those who have ever gambled online (12%) were more likely to use their parents’ account to gamble with their permission (5% of all surveyed). Two percent of those surveyed had used parents’ accounts without permission.
  • In gaming, over half surveyed (52% of 11-16 year olds) knew of in-game purchase items in gaming, and 44% of these had paid money to open loot boxes. 12% had ever played online gambling style games; 47% using an app.
  • Using a youth screen for gambling harm (DSM-IV-MR-J), identified 1.7% of 11-16 year olds as experiencing gambling harm, and 2.7% as at-risk gamblers, with boys at greater risk for problems (2%) than girls (0.7%).
  • Whereas most young people think gambling is dangerous (59%) and think they are well-informed about the risk (60%), with over two-thirds reporting they have not been influenced to gamble by adverts, the authors noted that around one in ten (12%) young people surveyed had followed gambling companies on social media, and 11% had received direct marketing from gambling companies.
  • The authors further noted that half of the young people had been spoken to about potential gambling problems and three quarters knew where to seek help. Most would seek help first from parents (53%) but this could contrast with two-thirds of them being with parents when they had been gambling. Also, 14% stated someone in their family or household had felt bad gambling. Most said their family would discourage them from gambling if they started gambling or found out that they had been gambling, however, 23% said they were allowed to gamble, but with rules.

Comment:

  • This is an important report because of its annual iteration, and because it has been commission by an influential body, the UK Gambling Commission.
  • There are important findings, especially that 11% of young people had gambled over the past 7 days, about twice as many than smoked cigarettes or used illegal drugs (albeit less than those who used alcohol). Particularly, that those who gambled were far more likely to have also used alcohol (over twice more likely than others surveyed), or used illegal drugs (four times more likely).
  • Also, although the authors used a youth gambling screen, it would appear that over the much larger group of gaming players surveyed (44% had paid money to open loot boxes), these were not perceiving this as gambling, despite growing evidence that paying for a chance to win something of value is in fact gambling, and many regulators have called for loot boxes to be regulated by gambling legislation. Had those statistics been included, the small increase in online gambling may have been considerably higher, while if included in the screen, may have signalled a different and more concerning participation rate.
  • In the questionnaire, ‘gambling’ referred to gambling online, but defined this as ‘Gambling websites/apps where you can win real money (e.g. poker, casinos, bingo, betting on sport or racing)’. Betting money to win items of value which now can be immediately sold for cash on other websites are not included, nor the fact that items are chased for their value, and money is spent for uncertain outcomes. Many overseas gambling regulators are promoting loot boxes to be regulated under gambling laws, however, at the time of surveying for this ongoing iterated research, this was not considered relevant enough for inclusion as gambling (and prevalence calculations), despite  noting that ‘52% of 11-16 year olds have heard of in-game items (e.g. weapons, power-ups and tokens). Of those who have heard of in-game items, 44% have paid money to open loot boxes/crates/packs to get other in-game items within the game they were playing and 6% have bet with in-game items on other websites outside the game or privately (e.g. with friends).’p.2
  • Therefore, even gambling with items won from paying money is not included in the gambling statistics, let alone winning the items from spending money for an uncertain outcome to win items of value. This may suggest that the participation rate in a more comprehensive but realistic definition of ‘gambling’, and the use of a gambling screen that better reflects this definition may result in far more concerning statistics for gambling amongst these young people.
  • Other concerns are the participation of parents in facilitating their children’s gambling, and that many of these parents would be the first resource for children wanting help as a result of concern around their gambling (many parents may normalise losses or minimise the harm effects). In the study, the children were spending their own money (other than when accessing parents’ accounts) and therefore they had more involvement in the gambling.

Literature:

Gambling despite financial loss – the role of losses disguised as wins in multi-line slots

Authors: Graydon C, Dixon M, Stange M, Fugelsang J.

Society for the Study of Addiction (2018) Addiction: research report. Canada, U of Waterloo. Doi:10.1111/add.14406

Findings:

  • The authors noted that many wins on EGMs were less than the amount wagered for that win, resulting in a net loss to the player. They identified these as ‘losses disguised as wins (LDWs).
  • ‘Near-miss’ research (some jackpot symbols on paying line with others in the line above or below) found players played significantly longer and were perceived as frustrating losses and players with moderate near-misses (30% compared with 15% or 45%) persisted with gambling over an ‘extinction phase’, suggesting an optimum near-miss rate occurred.
  • Multiline EGMs are highly popular with players, and LDWs were accompanied by visual and auditory events, and may be construed as wins (reinforcers) despite net losses.
  • The authors noted that research indicated that novice players did identify these reinforcers as wins (higher skin conductance responses equivalent to wins, but lower than losses), and led novice and experienced players to over-estimate the number of wins during playing. Some subtle effects occur where moderate numbers of LDWs can result in over-estimation compared with high LDWs, suggesting that the win over-estimation effect reaches a disconnection when perceived as too high.
  • Players (N=132) played 100 spins with random LDWs (low, medium, high) followed by continued playing at the players’ choice of time.
  • The aim of the research was to identify that different proportions of LDWs could result in different persistence or continued gambling despite financial loss, and that this would differ depending upon the degree of harm that the gambler was experiencing.
  • Gamblers with varying degrees of gambling risk or harm (non-problem, low risk, or higher risk) were designated by scores on the PGSI.
  • Gamblers were measured upon the number of voluntary spins (persistence)  during a losing streak.
  • The authors found that persistence varied by LDW frequency and gambling harm status. ‘Non-problem’ gamblers showed a linear trend, gambling for longer when LDWs were few, while low risk gamblers were not significantly different to others. High risk gamblers, however, were significantly affected by moderate numbers of LDWs, rather than the low or high LDWs and persisted longer in this mode.
  • The authors noted that, unexpectedly, ‘non-problem’ gamblers did not increase persistence with the moderate LDWs, but rather continued in a linear pattern in gambling, with longest in low LDW games, followed by shorter persistence with moderate LDWs, and least with highest LDWs. They concluded that for these ‘non-problem’ gamblers, actual overall wins were more important than perceived wins.
  • Moderate gamblers may gamble longer, but not so much as to be overly influenced by perceived (LDWs) over noticing actual win levels.
  • With high risk gamblers, persistence was highest, but at the moderate rate of LDWs (or ‘sweet spot’) suggesting they were influenced by moderate rates of LDWs (or misdirected), but there was a disconnect if too high a rate (similar to near-misses). The two effects differ; LDWs are miscategorised as wins, whereas near-misses are frustrating losses.
  • LDWs are perceived as increasing overall reinforcement rates of the EGMs.

Comment:

  • It is noted that those most affected by LDWs were those experiencing the most harm (even though restricted to moderate rates of these) suggesting that design of these machines could be modified to reduce LDW levels to decrease harm with the most affected.
  • The WAGER, the brief addiction science information source (Harvard), noted that ‘the results are important for responsible product design for manufacturers of (EGMs) since LDWs might increase the extent to which high-risk gamblers continue to play despite occurring losses’, and that education about LDWs (and other features such as near-misses) may reduce behaviours resulting in gambling harm.
  • More significant, is the fact that LDWs are deliberately misleading, and have proved to cause more harm (persistence) in those experiencing gambling harm. These issues raise further concerns that misleading programming of high-risk gambling products are able to persist, and are not treated as deceptive under normal product sale laws.
  • Clients attending treatment services should be made aware of this risk and this may raise motivation to reduce participation in future gambling for EGM players experiencing harm.

Literature:

Loot box engagement and problem gambling among adolescent gamers: findings from a national survey. (2019)

Authors: Kristiansen S & Severin M.

Addictive Behaviors, 103, April 2019, 106254

Findings:

  • The authors analysed the dataset in the national survey above (N=1,137) and noted that in comparing loot box engagement patterns and gambling harm severity, that nearly half of the respondents to the survey (45.6%) that were engaged in gaming in the previous year, were engaged in loot box activities.
  • Most gaming males (93%) had earned, bought, or sold items from a loot box compared with females (15%)
  • There was a significant positive correlation between loot box use and gambling severity even adjusting for core demographic factors. Highest correlation for gambling severity and gaming was those who had purchased or sold loot box items. 

Comment:

  • This is a direct correlation between gambling and loot boxes suggesting the need for supporting the very low opportunity in NZ to obtain help for gaming problems. Screening for gambling using an appropriate screen that also referred to gaming, obtaining information about spending patterns and risk for ‘gambling like’ behaviour, may reduce future direct gambling harm.
  • The NZ clinical gambling treatment workforce provides an opportunity to intervene early in the life of a person impacted with risk for such gambling harm.

Literature:

The role of emotion regulation in video gaming and gambling disorder (Nov 2019)

Marchica L, Mills D, Derevensky J, Montreuil T.

ResearchGate, 2019

www.researchgate.net/publication/337144595

Findings:

  • The authors noted that emotional regulation deficits (ER) have significant implications for mental health, and for psychopathology, however, that the knowledge of the relationships between ER and behavioural addictions remains low.
  • They noted those affected by their gambling often attempted to regulate or escape unwanted emotions, and that experiential avoidance predicted higher gambling harm. Such gamblers experiencing harm were unable to accept negative emotions and focused upon strategies that enabled escape and avoidance of negative affective states, with impairments to value long-term solutions over short term benefits and costs. They further noted that research showed those affected by gambling harm chose short term benefits (immediate higher value rewards despite longer term harm). Gamblers experiencing harm were unable to see ways to regulate emotions that may lead to better longer term solutions (Iowa Gambling Task). This suggests a lack of flexibility and inability to control impulsive behaviours that may be costly to the gambler.
  • Video gaming and gambling may be seen as maladaptive ER strategies.
  • This study involved a systematic review of the relationship between ER and behavioural addictions. N=2471 studies were analysed, of which just n=20 were deemed eligible for inclusion, with 14 of the 20 addressing gambling harm.
  • Outcome and sampling measures, results, effect sizes were analysed.
  • The authors found in 90% of the studies, lower emotional regulation was associated with greater video gaming or gambling disorder symptoms, with effect sizes in the medium to large range in 13 (65%) of the studies.
  • The authors concluded that emotional regulation plays a key role in behavioural addictions, and suggested potential prevention and intervention practices for addressing these and future recommendations.
  • In respect of interventions for behavioural addictions the authors concluded that ER deficits ‘should be considered as a crucial and specific target in psychological treatment and prevention measures of behavioural addictions’ p26. They further considered that as an example, that teaching how to label emotions, emotional awareness (how they express themselves in their body) will assist those with behavioural addictions to become aware and understand their emotions. Mindfulness, acceptance, and emotional tolerance through radical acceptance will assist in avoidance of impulsiveness often found in excessive gambling and gaming.
  • They noted that although males were over-represented in  gambling harm, females were likely to have a higher prevalence of ER deficits and that had the studies been more gender balanced, a higher ER effect may have been noted.
  • Finally, the authors recommended that research should identify those affected with more than one disorder, for example focus upon all behavioural disorders; also, where high ER exists, apply prevention strategies to address the development of behavioural addictions. Addressing ER therefore becomes a broader and more effective therapeutic approach ‘to be the most effective toward improved mental health outcomes and overall wellbeing’ p27.

Comment:

  • This is an important study covering 14 studies of gambling and 6 of gaming where similar findings of emotional deficits appear to be correlated (often strongly) with these behavioural addictions.
  • Escape from negative emotions can often be a driving force that acts as a barrier to help-seeking and recovery. They noted that research has identified that gamblers are focused upon instant gratification despite longer-term costs, and rather than only rewards (positive reinforcement), the attempts to escape ER may also act as a (negative) reinforcer.
  • The reward may remain, therefore, even through loss of money, and budget management may be less relevant for many gamblers, especially when gambling offers uncertain opportunities to solve financial problems, a further distracting benefit with hope.
  • The authors describe the benefits of ER regulation and tolerance, mindfulness and other cognitive behavioural therapies. DBT and ACT are third wave CBT therapies that provide several evidence-based approaches to address such ER deficits.
  • The clinical gambling harm minimisation workforce would benefit from extended training to provide such options for presenting gamblers (e.g. trauma-informed care approaches). Also, addressing other behaviours such as coexisting behavioural addictions may enhance change resilience, including gaming, where gambling behaviours may be blurred.  

Literature:

Gambling harm: a global problem requiring global solutions.

Authors: Reith G, Wardle H, Gilmore I (2019)

The Lancet: August 20, 2019

doi.org//1016/S0140-6736(19)31991-9

Findings:

  • In an editorial article in the Lancet, the authors noted ‘profound harms that can be associated with gambling and the impact these have on individuals, families and society’ p.1.
  • They noted that Swedish data identified a ’15-times increase in mortality among people with gambling disorder’ p1. And that 2% of all suicide deaths in Australia were related to gambling.
  • They further highlighted a public health approach, and that harm extends beyond the individual to society, describing interpersonal problems, abuse and neglect of partners and children, and criminal activity, with impact upon health and social care. They further noted that the harm was associated with social inequalities, with impact upon disadvantaged groups, and linked to many physical and mental health problems.
  • The authors described the focus of large gambling companies on Africa, with negative outcomes on youth, the poor, and suicide risk. Weak regulations, phone betting and interest in sports betting, all added to risk for harm.
  • They noted the need to address the vulnerability exploited by global gambling companies, and to address gambling as a global issue. They acknowledged that the WHO had identified gambling as a potential issue contributing to poor global health, but that ‘actions and recommendations needed from them to address gambling are not forthcoming (from the WHO)’  and a coherent strategy was required.

Comment:

  • This paper is an important document because of the status that the Lancet demands globally, as well as the voice of the influential medical field. Its call for the WHO to intervene further may be significant, as is the new public health focus for harm.

Literature:

Loot boxes and the convergence of video games and gambling (2019, September)

Zendle D & Bowden-Jones H

Lancet correspondence vol 6, September 2019

www.thelancet.com/psychiatry

Findings:

  • Although addressed in the correspondence section of the Lancet, the wide influence of this paper further demonstrated the interest of this topic.
  • The authors noted the behaviour of youth purchasing loot boxes with uncertain outcomes were similar to gambling and if not gambling, may lead to gambling, cities Drummond & Sauer (2018). They noted over half of the highest grossing mobile games contained loot boxes, while over 94% were deemed suitable for children aged 12 or over.
  • Impulsiveness by youth, and the appeal of risk-taking raised risk for youth (particularly teens who were more likely to use loot boxes) in using loot boxes.
  • The authors noted that many games shared key links with gambling sites. Clinicians working with patients who have gaming problems must be aware of the ‘quality of gameplay’ occurring to be aware of relevant clinical aspects.
  • The addition of loot boxes has become a ‘lucrative addition to the gaming market’ and should be addressed by policy makers, physicians, politicians, players and society, to protect gamers. 

Comment:

  • Again, the correspondence section is an influential part of the prestigious Lancet journal, with limited numbers of authors, offered this alternative to the main body of the journal.
  • In further analysis of the above study they were concerned at the absence of controls over young gamers who may be exposed to gambling or gambling-like opportunities.
  • The blurring of gaming and gambling has been overlooked by politicians, while clinicians addressing gaming or gambling may need  special knowledge about the other to provide effective treatment.