Effects and unintended effects of educational material.

A major theme was that, while existing educational messages and campaigns by governments and industry are often represented as effective, they are largely considered ineffective in contributing to behavioral change in gamblers and to the reduction and prevention of gambling harm [52,54,59,65,76,78]. The emphasis on individual responsibility evident in many campaigns is considered a factor that decreases the effectiveness of educational messages and campaigns, seeking instead to produce subjects who uncritically accept the existing situation, where individual responsibility is presented as the key solution to gambling harm [65,55,77].

One effect of messaging with a focus on individual responsibility is the production of feelings of shame in people experiencing severe gambling harm, which may also lead to avoidance of help-seeking [59,74]. To be effective, young people in school, gamblers and their close ones demand the inclusion of warnings on the risks of gambling products in educational messages [57,52,54,65,55,74]. Some school children preferred messages with a focus on personal responsibility to the kinds of warning messages used in other public health campaigns (e.g., smoking) [57]. A suggested improvement was also tailoring messages by risk level and demography [59,55].

Our interpretation is that the industry portrayal of individuals as both the cause and solution to gambling harm conflicts with other stakeholders’ calls for developing more effective educational interventions. There was little refutational evidence presented in the studies included on the theme of effect and effectiveness of educational interventions.

The figures of responsible and irresponsible gamblers.

Across studies and jurisdictions, a theme to be noted was the focus on the figures of responsible and irresponsible gamblers. The dichotomy between the responsible or rational gambler who practices self-control while gambling and the implied irresponsible or irrational gambler who belongs to the vulnerable minority lacking self-control is produced and reproduced in educational messages and campaigns [54,76,77,48]. Instead of reproducing and reinforcing the figure of the responsible gambler, it was suggested that citizens should be provided with more precise information on gambling harm and the risks of gambling products [54].

Our interpretation is that the dichotomy between the common rational gambler and the uncommon irresponsible gambler highlights that in much of the educational materials, solutions to gambling harm are to be found at the individual level. This way of representing gambling harm is at the heart of the politics of gambling and responsible gambling.

The structure and style of messages and videos.

As a minor theme, the studies included ways to improve the content and structure of educational messages on different channels. Overall, simple language is preferred, along with concise content and avoiding an accusing tone [36,75]. People experiencing gambling harm did not find the responsible gambling messages appealing or relevant to themselves, compared to the positive promotional messages [74].

The interpretation of this theme is mainly about improving the content and style of educational messages. The messages need to be straightforward, non-accusing, and more positive, to match up with the positivity of marketing messages.

Effects and effectiveness of self-exclusion or family exclusion order.

Several barriers to the effective implementation of exclusion programs were identified across studies and jurisdictions. Having to apply for self-exclusion for oneself or on behalf of a family member separately for each individual venue was considered a major difficulty by both gamblers and their close ones [38,42,45,62]. Consequently, bypassing or circumventing an existing exclusion becomes easy, reducing the intervention’s effectiveness. Relatedly, gamblers considered that monitoring or enforcing the self-exclusions at venues was often poorly executed, likewise decreasing the effectiveness of the intervention [42,62]. Moreover, many gamblers and gambling venue staff were generally critical of the implementation of self-exclusion programs and did not consider them effective or beneficial [42,45].

Overall, self-exclusion was considered beneficial by both gamblers [42,45] and their close ones who had applied for family exclusion [38]. Self-excluders and venue staff members viewed treatment and support as important in complementing a self-exclusion program [45,62]. In addition, longer self-exclusion periods with restricted revocation were supported by gamblers, especially for people experiencing serious gambling harm. The idea of tailoring the length of the exclusion period to the needs of the individual was also supported by gamblers [42,45,62]. Some venue staff supported an unlimited self-exclusion period for people with gambling problems, while others opposed this [45].

Overall, exclusion programs may have benefits that can be enhanced with additional support and the possibility to tailor the length of the exclusion without too easy revocation. Conversely, the ease of bypassing the exclusion via alternative gambling opportunities, and lax enforcement hamper its effectiveness.

Registration barriers and facilitators.

Similarly to the overall effects of exclusion programs, self-excluders saw registration as too time-consuming and requiring resources, as one needs to register separately at every electronic gambling machine venue [42,62]. Improving the ease of registration with the possibility of multi-venue self-exclusion and easy-to-use online registration by, e.g., a mobile phone application, were supported to correct this [42,62,63].

Self-excluders and non-excluders reported several barriers to registration: shame and concerns over staff attitudes, negative experiences with staff, staff trying to talk customers out of the idea of self-excluding, and lack of information or staff knowledge [42,45,62]. As a corrective measure, gamblers suggested that staff should encounter potential self-excluders in a way that takes their emotional state into consideration [42,45,62,63]. Family members or other close ones often played an important role in the decision to self-exclude [38,42,62,63]. An additional challenge for registration may be that gambling venues are seen as socially important meeting places [42,45]. According to some self-excluders, denial of their own problems was an additional reason for not self-excluding [42,45].

Accessibility of exclusion with extensive coverage, as well as support and compassion from staff, facilitate registration to self-exclusion programs. In contrast, the overall laborious and distressful registration processes can be a major barrier to self-exclusion. Moreover, there is evidence of gambling companies prioritizing revenue over actively assisting and approaching gamblers at venues, possibly preventing the inclusion of many people experiencing gambling harm from self-exclusion programs.

Effects of availability changes.

Effects of restrictions constituted a major theme. In Italy, industry representatives and business owners accommodating gambling machines emphasize the negative financial consequences of such restrictions [68]. In Finland, some casual gamblers reported a negative impact on their enjoyment [51]. However, concerns about migration to other gambling products—such as online gambling, illegal gambling, or gambling in regions without restrictions—were frequently cited as a cross-cutting consequence of availability restrictions, especially by representatives of the gambling industry and associated businesses [51,68,69]. Gamblers reported mixed effects of migration to other gambling products, with some experiencing increased spending and harm, while others benefited from online gambling features, such as the ability to set spending limits [51,69].

Other perceived effects of availability restriction related to gambling harm were also reported. Gamblers experiencing varying levels of gambling harm reported that reduced availability of gambling machines had a positive impact, including lower expenditure, fewer harms, reduced distress, and prevention of habitual gambling [51,69].

Conversely, perceived effects of increased availability included higher spending and greater harm, as reported by both gamblers and other stakeholders, such as small business owners accommodating gambling machines [68,51].

Overall, our interpretation suggests that changes in availability may be linked to experiences of harm and changes in individual expenditure. Moreover, perspectives and arguments on the effects of availability regulation vary significantly based on stakeholders’ positions. The gambling industry and its collaborators argue that availability regulations lead to revenue loss and, most importantly, migration to alternative gambling products or formats. This bypassing or circumvention of restrictions is often presented as rendering availability restrictions ineffective.

Public health and economic justification of availability regulation.

The minor theme shows that both economic and public health arguments are used to justify availability restrictions and liberalizations [68,35]. In Quebec, the government justified restricting offshore online gambling as a public health measure, though the true intent seemed to be to protect the state monopoly and secure revenue [35]. The government’s expansion of gambling machines is financially justified, with Italy’s economic crisis pushing businesses to install them and financially strained individuals to gamble for income or escapism [68].

The fluidity of economic justifications used by governments and other key actors both to support and oppose availability restrictions and liberalizations poses a challenge for prevention and public health. This highlights the (often problematic) dual role of government as both the regulator of gambling operations and their direct beneficiary via taxes or ownership in gambling companies, even as these operations produce harm to the very people the government is meant to represent [85].

Interpretation of law, regulation, self-regulation and the free market.

This major theme covers the dynamics related to the gambling industry, media, government, and other stakeholders in influencing how gambling marketing is regulated or not regulated. The industry and media emphasize challenges in interpreting the meaning of “moderation” in Swedish law, necessitating the wait for case law, while governmental authorities see the interpretation as clear [39]. In Finland, while the industry and regulator disagreed on the interpretation of the marketing law, the regulator’s view prevailed, unlike in risk assessments where companies could invoke their own self-regulatory codes [70].

The industry and media argue that regulation is not needed, as the self-correcting force of the market will naturally decrease the volume of gambling marketing. Arguments against restrictions based on principles of freedom of trade, freedom of expression, and democracy were also expressed [39]. However, when the regulator established an interpretation of the law, it maintained that the focus of marketing needs to be on channeling existing demand toward legal supply without creating new demand [70].

Self-regulation and revenue priorities dominate government, industry, and media agendas. The industry views restrictions as a competitive threat, while harm prevention groups see all marketing as excessive and doubt industry compliance [39]. Australian youth acknowledge the complexity of marketing restrictions and highlight the government’s conflicted role as both regulator and revenue recipient. They also see insufficient action and awareness around gambling harm, despite recognizing the need to regulate marketing across media [65,66].

Given the differing views of the gambling industry, media, and other stakeholders, careful definition of content and interpretation of marketing restrictions is crucial to limit the exposure of various population groups, such as young people, to the potentially harmful impacts of gambling promotion. Without clear legislation, strong industry opposition to regulation may prevail due to their business interests and preference for self-regulatory alternatives.

Effects and impacts of marketing as justifications of restrictions.

A minor theme was that there are many different perceived effects of gambling marketing. These effects were used as justifications for restrictions on marketing. One response is annoyance over exposure due to the overwhelming volume of advertisements in different channels and environments [39]. Prolonged exposure to advertisements may also affect young people’s attitudes and decisions [66]. Moreover, having promotional and warning content in the same messages was perceived as contradictory by young people [65]. Women also recognized that gambling companies seek to appeal to them with specific products and commercial content, inciting them to gamble more [54].

Thus, it is possible that marketing messages may impact the attitudes and behavior of different population groups, justifying the need to restrict gambling advertising.

Consumer protection.

Restricting gambling advertisement content and protecting consumers emerged as a subtheme. State-controlled operators favored categorizing products by risk, while private online firms preferred categorizing gamblers, reflecting their reliance on high-risk online gambling revenue [39]. Young people exposed to pervasive advertising stressed the need for clear risk information and youth engagement in policy design [65,66]. Women also supported marketing restrictions to protect children [54].

Private gambling companies may oppose regulations on the content of advertisements. Still, warnings about the risks of gambling could be included in gambling marketing to counter their positive content and effects. Engaging target groups in designing marketing restrictions and the content of counter-messaging is important, as they may have experiences and insights that policymakers and officials do not know.

Responses, perceived effects, and usefulness of the feedback.

Main theme on the views on the benefits and effects of behavioral feedback showed variety across studies. While feedback could be beneficial for some gamblers to a limited extent or enable a change of focus, it was generally not considered a significant contributor to behavioral change [31–33,47,73]. Overall, both staff and gamblers, including those experiencing gambling harm, at gambling machine venues did not consider automated mandatory feedback effective in changing behavior [47]. Gamblers and staff found the feedback distracting, frustrating, and annoying [31,47]. However, some machine gamblers found the feedback helpful in maintaining control and keeping track of spending [73]. A feedback tool was considered helpful, especially for t on personal expenditure over time was supported and considered useful by gamblers [31,73].

Feedback may enable a change of focus, but generally, gamblers question its relevance and may even find mandatory feedback annoying and frustrating. The feedback is often not considered relevant to oneself, as it is perceived that people experiencing severe gambling harm are the primary target group.

Privacy concerns, content, and accuracy of the feedback.

The accuracy, validity, and content of the feedback were sometimes contested, given differences in income or the possibility of several people using the same account. Sometimes the feedback was considered nonsensical, accusatory, or even insulting [32,33]. Still, some online gamblers found behavioral feedback easy to read and grasp [32]. Some gambling machine venue staff considered feedback messages intrusive and were also concerned about increasing institutional control and monitoring [47,73]. Privacy concerns and embarrassment arose from the potential visibility of feedback content to others, as well as concerns over access to sensitive player data [47,73].

The implementation of personal behavioral feedback may be perceived by gamblers as governmental or gambling industry monitoring and control or as an intrusion into personal freedom. Moreover, as behavioral feedback is ultimately based on collecting behavioral data, the storage and safety of that potentially sensitive data can be a privacy concern. Additionally, if the tone of the feedback is interpreted as accusatory, it may arouse negative emotions and be counterproductive to the aim of preventing and reducing gambling harm.

Barriers to interrupting gambling of customers at venues.

A major theme across studies and jurisdictions was the tension experienced by staff between being employees in a profit-seeking gambling business and the demands of caring for the wellbeing of customers. This was conceptualized in the second-order interpretations as role conflict or role ambiguity—the challenge of caring for customers’ welfare while fearing loss of revenue, sanctions from employers, or loss of personal income if approaching customers proactively [41,28,29,50]. Staff in gambling machine venues and casinos often rationalized their reluctance to intervene upon seeing potentially harmful behavior due to a lack of training and experience required to identify signs of gambling harm [28,29,50]. Moreover, not knowing the financial or overall situation of the customer was a reason not to approach them [41,28,50]. Additionally, staff considered existing legislation and industry codes of conduct as not allowing proactive approaches to customers, including concerns over legal repercussions if staff unintentionally offend customers [41,28,50]. Fear of angry customer responses and complaints also emerged as a common concern [41,28,50].

In contrast, management rationalized abstinence from intervening by pointing to the availability of support and self-exclusion information at the venue [28]. Additional barriers for staff included customers’ refusal to acknowledge a possible problem or ignoring the presence of the employee [41,50]. Sometimes staff members felt that intervening represented an invasion of customers’ privacy or found it emotionally laborious to face a customer clearly experiencing gambling harm [41].

Challenges to interrupting risky behavior include the responsibility placed on frontline staff to manage emotionally charged encounters with gamblers experiencing harm. This transfer of responsibility to frontline venue staff refers to the ways employees are “walking on a tightrope” [29] when trying to balance the conflicting demands of extracting revenue from high-spending gamblers experiencing harm and the duty to care for their wellbeing. Care for customer welfare, business profits, and employee income often come into direct conflict. Ultimately, staff carry the burden of implementing the policy of interrupting harmful gambling behavior.

Responses and effectiveness of automated and human interruptions.

A minor theme related to how interruptions in gambling are perceived and responded to by gamblers. Managers at venues viewed customer support procedures as clear and effective [28]. However, staff criticized automated alarm systems as ineffective, noting that behavioral interventions rarely followed the alerts [29]. Interruptions were also absent even when revenue spikes and overspending were evident [50].

Overall, both automated and human interruptions of risky behavior at venues were largely considered ineffective by gamblers and staff. Some managers of machine gambling venues considered practices based on existing codes of conduct functional. Managers, perhaps more strongly representing the business interests of the venue, foreground the functionality of existing policies, while staff implementing the policies in practice see them as inadequate.

Effects and impact of spending limits on self-control, harm, and user experience.

Gamblers with different levels of risk generally considered spending limits effective and beneficial in reducing expenditure and controlling gambling across jurisdictions [31,73,37,46,71]. Moreover, extending spending limits across venues and sites was seen as increasing user value, uptake, and preventing the possibility of circumventing the limits [73,37,46]. However, some gamblers did not find spending limits and related player identification useful, believing such interventions would take the enjoyment out of gambling, result in stopping gambling, or lead to migration to other gambling products [73,37].

Overall, studies indicate that gamblers perceive potentially beneficial effects on spending and self-control. Spending limits help maintain control over gambling and provide a sense of safety while gambling. Universal limits without the option to circumvent them would potentially enhance effectiveness. However, gamblers have important reservations, viewing spending limits as reducing enjoyment, or not being relevant or beneficial to themselves, but only to others. Migration to other gambling products, such as online gambling, was considered a possibility with mandatory spending limits.

Issues with privacy, stigma, and freedom.

As a minor theme, privacy concerns were raised about who has access to data and how it may be used by the government or gambling industry. People experiencing gambling harm regarded the use of identification cards at venues in front of other customers as stigmatizing [37]. Mandatory spending limits were viewed as restrictions on personal freedom, raising concerns about government and industry monitoring and misusing player data [73].

Spending limits require personal identification and are potentially considered as surveillance and control by the gamblers, with the suspicion that data is collected and used data against players’ interests. These concerns were notably expressed by machine gamblers in Australia, indicating that gambling is seen there notably as an activity belonging to the private sphere rather than a public health issue.

Easy and flexible use.

Another minor theme was related to the way gamblers emphasized the need for a spending limit scheme that is easy to use and flexible in setting and adjusting personal limits, even on short notice and without delay [73,37,46]. Representing and implementing the spending limit scheme in a fun and light way was also supported [37].

Our interpretation is that for many gamblers flexibility and user-friendliness in setting limits were core values. However, the apparent difficulty of linking these wishes with the aims of preventing and reducing gambling harm effectively was not addressed by the participants.