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Gambling harm is a growing public health concern affecting individuals, families, and communities across the world. Given their current and future potential roles within healthcare teams, it's essential for medical students to be well-informed about, know how to identify, and be confident in providing treatment and support to patients who may be suffering from gambling harm. This is why our charity recently hosted a medical education course on gambling harm for third-year medical students, which used a simulation-based format with individuals with lived experience acting as real patients. The course was designed to provide medical students with an immersive and interactive learning experience that would help them better understand the complexities of gambling harm and the impact it has on individuals, families, and communities. By using a simulation-based format, the course aimed to create a realistic and engaging learning environment that would help medical students to develop their skills and knowledge in a practical and hands-on way. The course was designed by a team of experts on gambling harm and medical education, who provided an overview of the latest research in gambling harm. This was followed by a series of interactive simulations, in which individuals with lived experience acted as real patients and shared their personal stories and experiences with the medical students. The medical students were first tasked with empathetically and sensitively gathering a history from a patient presenting with a symptom that may seemingly be unrelated to gambling harm. This was then followed by a more thorough assessment of other gambling harms as well as an evaluation of the risks to the patient and others. Lastly, the student doctors worked together to provide support and resources to the patients. Through these simulations, the medical students were able to see first-hand the impact that gambling harm can have on an individual's life and the importance of asking direct questions to promote early identification. Our lived experience delivery was particularly impactful for the medical students, as it provided an authentic perspective on the challenges and complexities of gambling harm. Individuals with lived experience shared their stories and provided insight into what it's like to live with gambling harm either from their own gambling or from another person's gambling, and the impact that it has had on their lives. This helped the medical students to understand the importance of empathy and compassion when working with patients who may be struggling with gambling harm and its stigmas. The simulation-based format of the medical education course was a great success, with the medical students expressing that they found the experience to be incredibly valuable and impactful. They reported increased confidence to identify and treat patients who may be suffering from gambling harm and appreciated the opportunity to put their knowledge and skills into practice in a safe and controlled environment. In conclusion, our charity's medical education course on gambling harm was an important step in preparing medical students to tackle this growing public health concern. By using a simulation-based format with individuals with lived experience, the course provided a hands-on and immersive learning experience that helped the medical students to develop their skills, knowledge and attitudes in a practical and impactful way. We believe that this type of education is crucial for healthcare professionals, and we will continue to advocate for its importance in undergraduate education. What did you like most about the sessions today? "Having real family members affected by gambling made the session much more helpful as I could understand exactly what to do and not to do in a consultation" "Before the session, I was not aware of the [gravity] of the effect gambling has and the severity that it has on QOL. + How many people it affects + How it is not just gambling. But also the emotional/behavioural changes" "The structure of both sessions and how it was split into smaller groups which allowed us not only to learn more effectively but also improve our communication skills on sensitive topics." What did you dislike most about the sessions today? "N/A (10/10 session) I would recommend to other med schools" "There was nothing I would change" "I wouldn't mind if the session was longer." Figure 1. Column chart showing student perceptions on helpfulness of sessions towards gambling harm competencies where 1 = not at all helpful and 5 = very helpful. The mean is plotted with 95% confidence intervals. Figure 2. Column chart showing student perceptions on helpfulness of the lived experience delivery of the sessions where 1 = not at all helpful and 5 = very helpful. The mean is plotted with 95% confidence intervals. Figure 3. A donut chart showing proportions of student preferences for quantity of gambling harm education at the undergraduate level. Abstract report Footnote: "Three years ago, I was a 4th Year Medical Student at Imperial College London realising that: I had experienced gambling harm all my life Gambling harm is one of the most significant modifiable risk factors for health That the issue is extraordinarily neglected relative to other similar issues It bothered me that I had never encountered gambling harm teaching in my medical education and that this would be the norm across undergraduate teaching domestically and internationally. (Now that I'm practising medicine as an FY1 doctor, I come across gambling harm regularly but often only because I have asked.) Therefore, in October 2019, I started my efforts to change this. Since then, we’ve created resources with medical education providers with a vast reach, namely, Geeky Medics and Osmosis – Medical Education. We’ve now gone a step further in making a decisive impact in gambling harm medical education through a successful course designed and delivered by individuals with lived experience course to medical students directly. We're extremely pleased with the feedback that we have received and the impact that this course will have on the students, their loved ones, and patients. We look forward to and strive to see gambling harm being considered and tackled alongside alcohol misuse, tobacco use, and drug misuse in medical education and healthcare practice." Dr Kishan Patel Chair of the Board of Trustees at Gambling Harm UK

Introduction The Betting and Gaming Council (BGC) was formed in 2019 as a merger of three different ‘industry associations’; the Remote Gambling Association (RGA), the Association of British Bookmakers (ABB) and the National Casino Forum (NCF).[i] These associations represented various sectors of the UK’s gambling industry whose interests had not always been aligned.[ii] With the formation of the BGC, however, the industry has created a unified body to advocate on its behalf.[iii] This advocacy, however, is not the aspect of the organisation that it stresses to the press or the public. Instead, the BGC, since its creation, has styled itself as a ‘standards body’ first and foremost, as CEO Michael Dugher is quoted in bold on their website ‘Our number one priority remains to raise standards and drive big changes’.[1] And whilst the BGC has championed several initiatives to promote safer gambling, their effectiveness has been questioned; the Guardian’s Rob Davies refers to much of the work as ‘cosmetic rather than profound’.[1] The BGC’s role as representatives and advocates of the industry is not immediately apparent and is always couched in the language of promoting industry standards; below Dughers’ quote (and in a much smaller font), the BGC’s stated mission is: “To champion the betting and gaming industry and set world class standards to ensure an enjoyable, fair and safe betting and gaming experience for all our customers.”[1] And its purpose: “To provide a forum to facilitate collaboration, sharing of best practice, drive and champion standards, and create a single voice for the industry.”[1] Despite this downplaying of its role as an industry-founded and industry-funded organisation, the BGC, like its forebears, is first and foremost a lobbying group for the gambling industry. Below we examine how and why the BGC was formed, the influence and connections it exerts, to what extent its claims of industry self-regulation can be taken seriously and finally, we will look at some of its strategies and tactics. FOBTs, the industry’s lost battle and the formation of the BGC Before their maximum bet was reduced by law from £100 to £2 in 2019, ‘fixed-odds betting terminals’ (FOBTs) were out of control. They represented over £1 billion lost a year by people who gambled, a disproportionate proportion of their players were ‘problem gamblers’ (13.6%, rising to over a quarter when including those at ‘moderate risk’), and they were primarily responsible for overcrowding high streets with betting shops.[2] By 2017, these problems, combined with the heart-rending stories of victims, coalesced into a media storm, with FOBTs dubbed the ‘crack cocaine of gambling.’[3]Unsurprisingly, the same year, the government launched a ‘consultation on a range of options on cutting maximum stakes.’[4] With each machine bringing in more than £50,000 a year and generating a total of £1.2 billion in income, the industry launched a defensive action. [3] This action would be spearheaded by the Association of British Bookmakers (ABB) and its CEO Malcolm George. Much of their effort was unsophisticated, with Malcolm George often railing against a ‘media panic’ induced by ‘those with their own commercial interests at heart’.[5] George was not entirely incorrect; the industry was divided on FOBTs, with some organisations backing reform and the ABB’s counterpart, the Remote Gambling Association, ‘content to stay out of the matter’. [3] Such heavy-handed attacks, however, did the ABB no favours. As with much lobbying, however, the primary battle was not in the press but in parliament. Here the ABB acted with much more sophistication and in a manner still emulated by its successor, the BGC: Firstly, the ABB commissioned KPMG (an accounting firm) to write a report on the impact of cutting FOBT’s maximum stake to £2; the report found that this would cost the industry a staggering £639 million and cause 15-21,000 job losses. It was, however, deeply misleading as the ABB had dictated the parameters of KPMG’s report in such a way to ensure a beneficial outcome. As KPMG notes, the report was ‘performed to meet specific terms of reference’, with certain estimates’ agreed with the industry’ and ‘should not be regarded as suitable to be used or relied on by any other person or for any other purpose’.[6] Despite this, the report was circulated among MPs and Civil Servants; it was used in ‘Treasury modelling’ and even cited by the Chancellor of the Exchequer, Philip Hammond.[3] Secondly, it would seem that the industry’s allies in parliament attempted to delay or axe the incoming £2 stake limit proposed by then Sports Minister Tracy Crouch. As Crouch would report, Philip Davies lobbied the Culture Secretary Jeremy Wright against the policy; after that, the Treasury and chancellor Philip Hammond (who cited the erroneous report) took over. Crouch then resigned in protest, triggering outroar and a rebellion which forced the Treasury to backtrack. Crouch has stated that without her resignation, she does not believe the policy would have gone ahead, given the Treasury’s and Hammonds’s ‘scepticism’, no doubt influenced by the misleading KGMP report and lobbying by pro-industry MPs.[3] With these late dramatics, the ABB had been defeated, and the industry’s reputation damaged. It was clear to gambling firms that if they wanted to weather public outrage and growing calls for reform, they would need a modern and sophisticated organisation to “champion” their interests. Thus, in 2018 the Betting and Gaming Council was formed. The BGC: buying influence At its formation, the BGC was already a formidable beast. It appointed a veteran lobbyist Brigid Simmonds as chairman. More importantly, it hired Michael Dugher, a former Shadow Secretary and Labour MP as chief executive and Kevin Schofield, a veteran journalist and former editor of PoliticsHome, to run the organisation’s communication strategy.[3] All the contacts and experience in this core team have undoubtedly been useful to the BGC in various ways, some of which we trace below. With the appointment of Kevin Schofield, the BGC had hired an experienced journalist and a man fully capable of running the organisation’s communications strategy. Perhaps it was this canny understanding of communications that caused PoliticsHome (a news source read by MPs and political advisors) to go from publishing articles broadly sympathetic to gambling reform to publishing no less than eleven articles written by the BGC or its staff in the eighteen months since they hired Schofield.[3] Or perhaps Schofield retains friends and influence at PoliticsHome, for which he was an editor for five years. Similarly, since his appointment, niche BGC reports have received favourable coverage by Schofield’s former colleagues in both the Sun and the Sun on Sunday.[3] Somewhat more challenging to map is the influence of former shadow minister Michael Dugher. Dugher is a man with numerous contacts from his time at the forefront of political activity; he has undoubtedly helped the BGC meet with and influence officials, ministers and MPs. The nature of such lobbying means that we can only speculate on the extent of his work. What we can note, however, is the apparent influence and reach of the BGC, whose staff met with DCMS officials seven times between October and December of 2020 (the period immediately before the Government’s Gambling Act Review was announced).[3] Perhaps the most well-publicised (alleged) exertion of Dugher’s influence was the hiring of former Labour Deputy Leader Tom Watson by Flutter Entertainment. Of course, Flutter is not the BGC, and there is no evidence that Dugher directly or indirectly influenced that decision. What is known is that Dugher and Watson are close friends, and despite Watson’s former vocally anti-gambling stance, he took a job for the industry, lending it both his expertise and reputation. Further, Watson has taken to using a favourite phrase of Dughers (and not many others) to describe activists in favour of gambling reform, that is, to call them ‘prohibitionists’ (despite the rarity of calls for an outright ban).[3] It is not just former MP’s the BGC has ties with (nor is the Dugher-Watson connection the height of the industry’s incestuous dealings). In November 2020, the BGC began paying current Conservative MP Laurence Robertson £2,000 monthly for 10 hours work advising ‘on sports and safer gambling’ (an hourly rate of £200).[3] Similarly, Philip Davies (the MP who lobbied to delay FOTB reform) got paid £50,000 for 124 hours of work advising Entain chief executive Kenny Alexander.[3] Alongside this, Davies has several former staff employed in the industry. Two of Entains senior officials previously worked in his office (head of safer gambling and external affairs Sophie Dean and chief of corporate affairs Grainne Hurst); the BGC also employs his former aide Camilla Toogood as its ‘government relations manager’.[3] Whilst there is nothing technically wrong with hiring a host of Davies acolytes, it shows how the BGC and, indeed, the industry maintains a deep connection with those politicians it deems friendly to their cause. The BGC: self-regulation? Unlike the old Association of British Bookmakers or the Remote Gambling Association, the BGC’s purpose as a pro-industry lobbying group is not immediately apparent to the casual observer. In a rather successful PR stunt, the industry dropped the standard ‘association’ moniker in its creation of the BGC and has focused on messaging concerning the groups role as a ‘standards body’. The BGC stresses this role at every opportunity and indeed, the organisation has championed several voluntary initiatives aimed at the protection of consumers. This has led many commentators to attribute a genuine concern for those affected by gambling harm. However, such exercises by the industry are best viewed as thinly veiled publicity stunts, primarily tokenistic and driven by the desire for self-preservation, which attempts to mask the actions of an industry desperately trying to fend off outside regulation. Take, for example, two instances of BGC “championed” reform. Firstly, the much-publicised whistle-to-whistle ban on gambling advertisements during live sporting broadcasts. The ban, agreed on in 2018, was labelled a ‘huge success’ in the BGC’s annual review and has been held up as something of a crowning achievement for the organisation and as proof that effective self-regulation is possible.[7] Indeed, the BGC claimed that the initiative had reduced the number of gambling ads seen by 4-17-year-olds by a staggering 97%.[8] The reality is substantially different; over the first year of the ban, gambling ads across all TV channels fell by about 11.3%.[9] Whilst this might seem substantial, two factors undermine the BGCs narrative. Firstly, despite a ban on tv advertisements during broadcasts, the broadcasts themselves contained numerous gambling logos and advertisements; 9 of 20 premier league clubs and 17 of 24 championship clubs had shirt sponsorships, to say nothing of the numerous advertisements on pitch-side boards.[10] Secondly, the ban only served to accelerate the move to online advertising, which the industry was already in the process of making. Indeed, the 97% reduction in gambling ads seen by children boasted by the BGC is achieved through not only excluding all media except broadcast tv but also by examining only the number of tv ads seen over the span of televised football matches, not the overall number of televisions ads seen at other times.[3] In short, the ban is unlikely to have reduced gambling harm due to the omnipresent nature of gambling ads both online and through sponsorships during broadcast; similarly, it was almost certainly harmless to the industry, which already had a large amount of exposure through those sponsorships and online marketing. The main purpose for the ban seems to have been the positive news coverage it generated for the industry. Secondly, and of more minor importance, is the BGCs supposed support for gambling reforms. Notably, when the Gambling Commission introduced a ban on gambling on credit - a ban on gambling on debt (and thus likely creating more debt) - Dugher claimed the BGC had always ‘fully and publicly’ supported the ban.[3] Despite this, the Commission's own report indicated that ‘none of the remote gambling operators who responded supported the ban’.[3] The BGCs backers had opposed the reform, and the BGC had only thrown its weight in once it was already decided; rather than championing reform, the organisation appears to have attempted to gain credit for a reform its backers opposed. What these examples illustrate and what must be kept in mind is that the BGC is, first and foremost, a pro-industry body; its responsibility is not to those affected by gambling harms but to the various gambling companies that make up its membership. As such, the regulatory initiatives it has championed have been aggrandised and have only been incidentally helpful in reducing gambling harm (if they have at all). The BGC commits to such initiatives with the dual aims of improving the industry’s public image and of fending off government intervention – the alternative is that profit-driven private enterprises are funding an organisation whose goal is to reduce their profits through self-regulation. The BGC: bogus fear of a black market One of the BGC’s primary methods of pushing back against the prospect of greater regulation is to raise concerns over growth in the gambling ‘black market’ (unlicensed gambling operations). The argument being that much like the American prohibition, a draconian crackdown on the industry could lead to an explosion of an unregulated (and more dangerous) form of gambling. Whilst the prospect of growth in the black market should perhaps not be dismissed outright, the industry’s predictions are certainly exaggerated and cynically leveraged; as Paddy Power co-founder Stewart Kenny has noted, industry heads always ‘used the threat of the black market’ and ‘always knew it was a bit of a bogus argument’.[3] Despite Mr Kenny’s admission and others like it, the BGC has focused much of its efforts on framing its opposition to regulation as civic-minded warnings. Whilst the ABB of old might have railed against the prospect of regulation (and the APPG on Betting and Gaming certainly has), the BGC’s well-oiled PR machine has taken a conciliatory tone, offering notional support to ‘the Gambling Review’ whilst raising the spectre of the black market if regulation is taken too far, warning that it may lead to ‘regulated industry being smaller and the illegal black market growing substantially’.[11] Dugher and the BGC then call for the government not to limit regulation or roll back its gambling review but rather to ‘take an evidence-based approach’.[11] Whilst this may seem an uncontroversial and eminently reasonable approach, one must recall the KGMP report on FOBTs that was declared unfit for outside use by its authors yet still found its way into Treasury modelling, onto the desks of civil servants, MPs and even the Chancellor’s. The industry can and has created ‘evidence’ which suits their financial interests; the BGC’s network of influence means that often this evidence makes its way to decision-makers even when it is woefully inaccurate and unusable. It is unsurprising then that in 2019 the industry commissioned PwC to write a report on the size of the UK black market.[3] The report estimated that 200,000 Britons wagered 1.4 billion on black market operators every year; this eye-catching figure was dutifully spread around the press (with Schofield’s old colleagues in the Murdoch Press doing much of the heavy lifting).[3] The report was deeply flawed and had failed to distinguish between real website visits and ones generated by bots; it drew widespread criticism and a surprisingly strong statement from the usually reticent Gambling Commission, with executive Niel McArthur calling the report ‘exaggerated’ and ‘not consistent with the intelligence picture’.[3] Furthermore, it should be noted whilst the report was completed in August of 2019, the BGC, a self-described ‘standards body’, did not choose to publish it until 2020, just as the Gambling Review was initiated. Not deterred by this criticism, the BGC quickly published a follow-up alleging that wagers on black market sites had doubled during the pandemic and now equalled around 2% of those placed on legitimate sites.[3] As Davies notes with some scepticism, during the same period, wagers on legitimate sites increased by a comparatively modest 13%; the PwC report would suggest that during lockdown, people were drawn not towards the licenced operators whose adverts they saw daily but towards much riskier black market sites.[3] To refer back again to Paddy power co-founder Stewart Kenny this seems incredibly unlikely as most people are ‘not going to lend [their] credit card details to black market operators’.[3] [i] An industry association is founded and funded by businesses operating in the sector. Its purpose is to promote the interests of the businesses it represents. [ii] Most notably on the issue of FOBTs [iii] Since the absorption of the Senet Group in 2020, the BGC now represents approximately 90% of the UK's licensed operators. [1] Betting & Gaming Council. Our Purpose [Internet]. [cited 2023 Jan 6]. Available from: https://bettingandgamingcouncil.com/about-us/our-purpose [2] Channel 4. Gambling act was a ‘mistake’ confesses senior Labour politician [Internet]. [cited 2023 Jan 6]. Available from: https://www.channel4.com/press/news/gambling-act-was-mistake-confesses-senior-labour-politician [3] Davies R. Jackpot: How Gambling Conquered Britain. London: Guardian Faber; 2022. [4] GOV.UK. Government to take action on Fixed Odds Betting Terminals [Internet]. [cited 2023 Jan 6]. Available from: https://www.gov.uk/government/news/government-to-take-action-on-fixed-odds-betting-terminals [5] Financial Times. Why criticism of FOBTs needs to be played down [Internet]. [cited 2023 Jan 6]. Available from: https://www.ft.com/content/3304187a-7ff1-11e6-8e50-8ec15fb462f4 [6] Davies R. Government’s FOBT decision influenced by ‘discredited’ report. The Guardian [Internet]. 2018 Nov 12 [cited 2023 Jan 6]; Available from: https://www.theguardian.com/uk-news/2018/nov/12/government-fobt-decision-discredited-report [7] Betting & Gaming Council. ‘Whistle to whistle’ ban a huge success [Internet]. [cited 2023 Jan 6]. Available from: https://bettingandgamingcouncil.com/annual-review/responsible-advertising-2 [8] Betting & Gaming Council. ‘Whistle to whistle’ ban success [Internet]. [cited 2023 Jan 6]. Available from: https://bettingandgamingcouncil.com/news/whistle-to-whistle-ban-dramatically-reduces-number-of-betting-adverts-seen-by-children [9] Patel K. Gambling and voluntary bans [Internet]. 2021 [cited 2023 Jan 6]. Available from: https://www.gamblingharm.com/post/gambling-and-voluntary-bans [10] Association P. Number of clubs sponsored by betting firms is ‘disturbing’, say campaigners. The Guardian [Internet]. 2018 Jul 30 [cited 2023 Jan 6]; Available from: https://www.theguardian.com/football/2018/jul/30/campaigners-concerned-championship-efl-clubs-sponsored-betting [11] Betting & Gaming Council. New research reveals shocking size of Black Market gambling across… [Internet]. [cited 2023 Jan 6]. Available from: https://bettingandgamingcouncil.com/news/new-research-reveals

Would you know if a family member, friend, or employee was suffering from gambling disorder? How do you recognise it? Unlike alcohol or drug addiction where individuals show associated visual signs of their addiction those suffering from gambling disorder are less visible and one might say generally invisible. So much so that in those cases where individuals complete suicide family members say they had no idea their husband, wife, son, or daughter was suffering from gambling disorder. So being the invisible addiction, this poses a number of challenges to those family members or employers who want to help. I want to look at this from an employer's perspective and with the assumption that the employer is truly interested in balancing the success of the organisation with the well-being of their staff. Firstly though, we need to consider what impact the addiction has on one's mental state, especially when at the height of the addiction. To answer this I have to depend on the information that has been shared with me during general conversations with those recovering from the disorder. Also, as an affected other, I can look back on my son's own situation. They have explained it in a variety of ways but all imply that the only thing constantly on their mind was gambling or gambling-related for example looking for loans to fund their next bet and that they found it very difficult to concentrate on anything else. So much so, that their general performance and health declined. If you then link this to sleep deprivation either caused by playing online games through the night or lying in bed at night worrying about the consequences of their disorder, then in my own words it would suggest that they were in a mentally fragile state where they were more prone to making human errors. So, what might this mean to a business? Risk: If your business requires your employees to perform tasks that require high levels of concentration then could this be increasing product or service defects? In the worst-case scenario, this could result in an incident or accident leading to injury or fatality. Brand: Could your business brand be damaged as a result of the above risks? What damage would this do to your company image and to the well-being of your employees? Productivity: If your employees are not focusing on the task required to be delivered then it is likely their productivity will be less. If they are using technology as part of their work activities could they in fact be spending less time working and some of their work time gambling online? With mobile phones being one of the main modes for doing work and also for gambling online how would you know? Staff Well-Being: If you are committed to staff well-being do your policies and culture enable and encourage your staff to feel safe enough to discuss their disorder. If not you may find your sickness levels being increased and your risks increasing. Incident/Accident Reporting and Investigating Procedures: Do these look at the human factor and if they do, how do they assess the individual's mental health well-being at the time. In my view, the current level of harm from gambling disorder is underestimated as procedures do not look for this area of risk. For alcohol and drug-related accidents/incidents, taking a blood sample enables you to assess if these addictions are a factor. With gambling disorder, there is no such test. The aim of this post is to help employers to be more aware of this disorder and to think about how they respond appropriately to it. With online gambling products now offering a "casino in your pocket" 24/7; a high proportion of the population who like to gamble and with the National Audit Office in 2019 reporting that in the UK there are around 55,000 aged 11 to 16 year old problem gamblers with a further 85,000 assessed to be at risk, then this is something which is likely to be an ongoing issue which may grow further with time. So employers need a sustainable approach to respond to this. Whereas an employer can introduce random blood sampling to monitor alcohol or drug intake to mitigate this risk, this cannot be done for gambling. The World Health Organisation states that " The gambling related burden of harm appears to be of a similar magnitude to major depressive disorder and alcohol misuse and dependence. It is substantially higher than harm attributed to drug dependence disorder". Interestingly, many of those I have met in recovery from the disorder are becoming or have become more successful in their employment life. This suggests to me that employers can get a win: win by doing the right thing. I am aware that by writing this post some employers could just try to identify and dismiss those with gambling disorder from the organisation. The stigma around gambling often portrays individuals as selfish and weak. This is not true. This fails to recognise that this disorder needs treatment and support like any other. Also, such an approach will fail to reduce organisational risk. In fact in my opinion it will increase it. I am, however, hopeful that there are more employers who truly care about their staff's well-being. Recognising that they are key to their success and by looking after them when they need help, they in return will do their best for their employer. If you would like to discuss gambling disorder further with people who have lived experience, then please contact Gambling Harm UK (GHUK). https://www.gamblingharm.com/contact

The PSHE curriculum was updated in September 2020 to include education surrounding gambling harm for the first time. [1, 2] Despite this change, compared to drugs, alcohol and tobacco education in Relationships and Sex Education (RSE) and Health Education, education on gambling harm is neglected. [3] There is no mention of gambling education in the PSHE primary education curriculum (Table 1) despite the increasing convergence of gambling and gaming. In secondary education, pupils are only required to learn about the risks of online gambling and debt accumulation (Table 2). There is no mention of addiction to gambling and the physical and psychological risks and consequences on the individual who gambles and those around the individual who gambles. Unlike what is seen in the curriculum for drug, alcohol, and tobacco education, there is also no mention of links to other mental health conditions. The difference in the amount of coverage on the PSHE curriculum shows gambling harm is not taken as seriously as alcohol and substance addiction despite the WHO reporting that "the gambling-related burden of harm appears to be of similar magnitude to harm attributed to major depressive disorder and alcohol misuse and dependence. It is substantially higher than harm attributed to drug dependence disorder." [4] It is also important to note that gambling harm is only included in the curriculum within 'internet safety and harms' in spite of a significant amount of gambling harm arising from land-based venues. Moreover, the inclusion of gambling disorder in the DSM-V in the ‘Addictions and Related Disorders’ category alongside substance addictions suggests the need for a holistic and overarching view of addiction in meaningful education and awareness. [4] Table 1 – Primary By the end of primary school: Note. Taken from gov.uk website (3) Table 2 – Secondary Schools should continue to develop knowledge on topics specified for primary as required and in addition, cover the following content by the end of secondary: Note. Taken from gov.uk website (3) References 1) PSHE Association and GambleAware launch gambling education handbook. Available from: https://pshe-association.org.uk/news/pshe-association-and-gambleaware-launch-gambling 2) T Menmuir. UK Schools to introduce Gambling curriculum for September 2020. SBC News. 16 March 2020. Available from: https://sbcnews.co.uk/sportsbook/2020/03/16/uk-schools-to-introduce-gambling-curriculum-for-september-2020/ 3) Government curriculum. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019542/Relationships_Education__Relationships_and_Sex_Education__RSE__and_Health_Education.pdf 4) Professor M Abbott. The epidemiology and impact of gambling disorder and other gambling-related harm. World Health Organisation. 26 June 2017 https://www.who.int/docs/default-source/substance-use/the-epidemiology-and-impact-of-gambling-disorder-and-other-gambling-relate-harm.pdf?sfvrsn=5901c849_2

Online gambling platforms are often misunderstood by those who do not engage in them, particularly ones which rely on an understanding of existing gaming mechanics. The convergence of gaming and gambling in this manner provides mediums which can be used to gamble using in-game items. eSports Many games, particularly those considered “eSports” (electronic sports) and the communities surrounding them provide an incentive to gamble. The online communities surrounding esports have grown in popularity following the rise of online streaming platforms, such as Twitch, professionally commentated web broadcasts, and a generally more connected and international online community. [1] Matches, and thus bets placed on them, maybe informally between friends or on the outcomes of top-tier competitors from anywhere in the world. Indeed, many recognised wagering operators now host cash betting on the outcome of esports matches. Something which is particularly prevalent with young people and those who are familiar with online games, however, is “skin betting”. Skin betting Skins, cosmetic game items which confer different aesthetics to in-game items, or provide different unlockable outfits for a character, are often acquired from in-game loot boxes, which provide different odds of acquiring different items. (see previous articles on simulated gambling and loot boxes). This means that on a consumer-led market, such as online “skin trading” platforms, (websites which allow the sale and purchase of other players’ unlocked items) some item prices are driven up due to a combination of their rarity, appeal, and desirability. Some gaming platforms, such as Steam, allow for the legitimate trade of items within the same platform games are published. Some items on marketplaces go for prices in the thousands, and some are very low-value. Skin betting occurs when people stake skins, typically relatively high-value skins, on the outcome of an event. These bets may be placed informally between friends, but more high-stakes skin betting tends to occur via third-party platforms that “hold” the staked items, and “payout” the skins to the winner of the bet. Skins act in this way as a form of virtual currency, and indeed, the purchase and sale of skins have their own economy. Skins can also be considered as “tokens” for real-life currency. [2] Though Steam does not allow direct conversion of skins back into currency and has limitations on purchasing in some instances, third-party programs may be used to “cash-out” of bets or purchases, allowing items to be traded for incredibly high amounts of real-world currency. These are transferred between players via a “bot”, or puppet Steam account, an automatic process coded by those who run the gambling website. eSports betting and gambling harm eSports bettors are a group which is vulnerable to harm. eSports bettors were found by one study to be far more likely to meet “problem gambler” criteria (64.8% of bettors) than those who engage in sports betting (17.3% of bettors). They were also significantly more likely than sports bettors to experience at least one instance of gambling harm. This may be due to the uniquely unregulated world of skin betting and eSports betting. There is an observable rise in those self-reporting their involvement in skin betting. Engagement of youth with in-game purchases and online gambling is high. The frequency of online gambling generally has increased in 2019, with 7% of 11-16 year-olds in the UK reporting having gambled online. There is also a gender bias in these statistics, with adolescent boys being significantly more likely to gamble in this way. According to Ipsos MORI data, 44% of young people aged 11-16 who had heard of in-game items have used the money to pay for them, and 6% had said that they engaged in betting with them. [3] In more recent studies, rates of adolescents who had engaged in skin betting were 11% in the UK, and in one Australian study, one in seven adolescents engaged in skin betting in the past year. Adolescents are 2.5x more likely to engage in betting with skins than with cash, and there is a robust association between skin gambling, overall gambling problems, and factors such as low wellbeing. The subcultures that youth engage in often actively encourage skin gambling with content creators and streamers advertising gambling on their media platforms, and other users in-game advertising the sites on their profile descriptions. Little research into the effects of this constant exposure has been conducted. Regulation of eSports and online skin betting Despite the harm caused, this method of gambling is currently exempt from many regulations, and even if regulation were to be put into place, it would be difficult to enact due to the nature of the industry. The market is largely consumer-led, and the third-party sites which facilitate the transactions can allow people to evade legislation in a particular country, which allows one to access the internet as if from a different country. [4] The introduction of age verification checks on these gambling websites, if made mandatory, may help with the issue of underage gambling, but there are ways for children and young people to circumvent current methods of age checks by using the identification of an older relative or friend. Meaningful legislation and regulation may be the most effective methods of harm reduction to implicate; in several areas. First is legislation regarding gambling advertising in online spheres and on a platform level; gambling is promoted to children via social media and by game influencers. A blanket ban on advertising for skin betting in user profiles would be an achievable goal, and would likely have support from a proportion of the user base, as many are tired of seeing these adverts. Second is the requirement for online skin gambling platforms to be licensed as online gambling operators and for video game gambling to be considered a form of gambling under UK law. [5] Overall, it is clear that gambling in video games and gaming communities is a growing industry, and steps must be taken to further understand, prevent, and ameliorate the harms experienced. [1]Edge, N., 2013. Evolution of the gaming experience: live video streaming and the emergence of a new web community. Elon Journal of Undergraduate Research in Communications, 4(2). [2]Thorhauge, A.M. and Nielsen, R.K., 2021. Epic, Steam, and the role of skin-betting in game (platform) economies. Journal of Consumer Culture, 21(1), pp.52-67. [3] Ipsos MORI via Gambling Commission. Gambling Commission publishes the 2019 Young People and Gambling report. (Oct 23, 2019) https://www.gamblingcommission.gov.uk/news/article/gambling-commission-publishes-the-2019-young-people-and-gambling-report [4]McLeod, C., 2017. More Than Skin Deep: Why It's Time to Go'All-In'on Skin Gambling Regulation. Available at SSRN 3159661. [5]Greer, N., Rockloff, M.J., Russell, A.M. and Lole, L., 2021. Are esports bettors a new generation of harmed gamblers? A comparison with sports bettors on gambling involvement, problems, and harm. Journal of Behavioral Addictions, 10(3), pp.435-446.

The impact of gambling-harm on LGBT+ (lesbian, gay, bisexual/pansexual, transgender and other minority gender and sexual identity) communities is one which has been severely under-researched. Preliminary evidence suggests LGBT+ populations may be more vulnerable to experiencing gambling harm as they are 1.5-2x more likely to be diagnosed with anxiety or mood disorders, and have higher rates of substance use, which are considered risk factors with disordered gambling.[1] [2] LGBT+ people, particularly the trans and gender-nonconforming community, also experience employment and pay discrimination, which relates to gambling harm as economic deprivation is associated with gambling harm. [3] Why is understanding the effects of gambling on LGBT+ Populations important? Other minority groups, such as minority ethnic populations and veterans, are beginning to become more well-studied in the fields of gambling research. LGBT+ general health outcomes are also gaining greater study. However, there are only a handful of publications specifically investigating the ways in which LGBT+ people engage in gambling activity. Through the understanding of the ways in which sexual and gender identity affects patterns of gambling and gambling harm, standards of care can be improved and public health prevention efforts can be developed. The Minority Stress Model Many studies dealing with minority populations reference the minority stress model, which describes experiences which arise from a conflict between minority group members and the dominant social environment. It was initially designed to focus on sexual minorities but has been expanded in recent years to cover other minority groups. It proposes that factors such as social rejection, prejudice, hiding and concealing aspects of one’s true identity, and ameliorative coping processes leads to stress. This constant background stress coming from the outside world can lead to negatively impacted physical and mental health outcomes, including engaging in more risky behaviour. [4] Studies into gambling harm Sexual minority communities (LGBT+) Data on the prevalence of gambling in sexual minority communities is somewhat conflicting. Older studies conducted by the Kinsey Institute indicated that gay men gambled less than their heterosexual counterparts, but gay women gambled more than their heterosexual counterparts. [5] Moreover, a 2021 study on sexual minority men, which indicated that problematic gambling was less severe in sexual minority men than in heterosexual men. [6] Studies on the potentially elevated risk for lesbians and sexual minority women were difficult to find, and there were no studies found which were published specifically on this topic. One 2015 study on 605 individuals found there were no significant differences in gambling between heterosexual and homosexual and bisexual populations. [7] Instead, the study reported that sexual minority participants were more likely to engage in problematic gaming. However, participation in this study was through self-selection, and the survey was presented as a self-test for problematic gaming and gambling, which may lead to sampling errors such as lack of awareness or honesty. The total number of participants who were sexual minorities limiting the applicability of these findings to wider sexual minority populations. There are also multiple studies which do indicate that overall, sexual minority groups are at elevated risk of problematic gambling. A preliminary study by the University of New South Wales in Australia attempted to study patterns of play in the LGBTI+ community. It was limited by smaller sample size (69), but included a range of ages, with a mean of 32. Within this sample, 20.2% of participants met the diagnostic criteria for problematic gambling – far higher than in the general Australian population, which is between 0.5 and 1%. [8]The motivations for gambling were mostly to improve or elevate mood, for social reasons, or to cope with negative thoughts, and problematic gambling was linked with increased use of substances and less self-control. This study was obviously limited in the fact that it had a small sample size and marketed itself as a study on gambling specifically, which may lead to a higher participation with gambling problems. However, the data it collected on motivations is particularly valuable. [9] One of the largest studies - sample size of 23,533 - on gambling-harm in gay, bisexual and lesbian young people focused on symptoms of disordered gambling in collegiate athletes. Results for gay and bisexual people of each gender were combined, as it was found that these two groups did not differ from each other in gambling disorder symptomatology. The findings reflected an elevated presence of gambling disorder symptomatology in gay and bisexual student athletes, when compared to their heterosexual peers. The study found the highest rates of gambling in gay and bisexual men. These findings indicate that gambling rates are a significant risk for young gay, lesbian and bisexual people and that further research into the topic is required. Transgender and gender-nonconforming communities Transgender people (those whose gender is different to their sex assigned at birth) and gender-nonconforming (a broader term encompassing those who may not specifically identify as transgender but exist in ways outside of the gender binary) are a group which are particularly vulnerable to minority stress, with 99% of trans people in TransActual’s Trans Lives Survey experiencing social media transphobia, and over 71% experiencing transphobic street harassment. Trans rights are also the current focus of a media culture war, and transphobic hate incidents are becoming more common, which has the potential to amplify the findings of previous studies, and exert a great toll on transgender and gender-nonconforming mental health. A study on 80,929 students, 2168 of which identified themselves as transgender or “gender diverse” reported that trans people assigned male at birth (transfeminine) had elevated risks of screening positive for problem gambling, with had higher rates of participation in all gambling behaviours than the trans people assigned female at birth (transmasculine) and cisgender female participants, except that transgender men and cisgender men had similar rates of casino gambling. Transgender participants, particularly transfeminine participants, reported a much greater risk of screening positive for problem gambling, with 8.9% of transfeminine youth screening positive for problem gambling compared to rates of 1-2.1% for cisgender youth. Data for transmasculine youth indicated that the rates of problem gambling were higher, but this was not statistically significant, likely due to the small sample size. Transgender participants were also more likely to report having gambled via lottery tickets, casino, or online gambling, indicating potential patterns of play. The survey was limited due to its sampling of students, for several reasons, including that transgender participants are more likely to skip school and therefore likely to not be included, and the fact that not all students who will eventually understand themselves as transgender will report so on the survey. However, its large sample size make it a study which provides a lot of useful insights into the fields of youth and LGBT+ gambling research. Limitations of current studies and further research needs: The dearth of research involving LGBT+ stratification is an issue. Most studies into harm in sexual minorities also tend either to aggregate LGBT+ identities, limiting our understanding somewhat, or have small sample sizes. Many of the largest-scale studies carried out into the effects of gambling-harm are on adolescent or young adult populations. Adolescence is a time associated with a lot of difficulty for many LGBT+ people, as the differences between them and their peers become more evident, and as such diminishes the generalisability of research findings to older LGBT+ populations. Older LGBT+ people may be affected by trauma associated with the HIV/AIDS crisis, as well as having their identities treated as more of a pathological issue than the way most people view sexuality and gender identity today. [10] These stressors which are more common in older generations may or may not impact rates of mental health issues, or influence the ways in which they are dealt with. There has been little research into how LGBT+ people interact with recovery services for disordered gambling, and they are excluded from much analysis on patterns of play. Adding a single question on sexuality and gender identity in more widespread studies on these issues would allow for a lot of beneficial data to be obtained, even if LGBT+ identities are not the central point of research. Barriers to adequate care When seeking care or treatment for disordered gambling, LGBT+ people may face particular difficulties which their cisgender, heterosexual counterparts may not face. Poor conduct of mental health providers - Mental health care providers have been found to have the misconception that mental health disorders stem from sexual minority status, even when there is evidence indicating that simply being a member of a minority group has no effects on mental health. [11][12] In a literature review which studied 14 published works on the topic, a significant barrier to accessing these essential health services for the gay population, was the heteronormative attitudes imposed by health professionals. The LGBT+ population generally is more likely to self-medicate and seek support from non-professional sources due to discrimination, and fear assumptions about their sexual orientation. The fear of having your real health concerns dismissed or linked back to your sexual or gender identity is a very present one. In a recent survey of almost 700 UK-based participants by the group TransActual, 70% of participants reported being impacted by transphobia in non-trans-related healthcare settings. [13] This shows the rates at which poor conduct by health providers is impacting transgender and gender-nonconforming communities today. Transgender clients are often not referred to by their chosen names by providers, as well as treated in accordance with negative stereotypes around transgender people – i.e. that they are predatory, confused, or a danger to themselves. Better training for mental health providers, specifically those who deal with gambling harm, is something which would hopefully improve participation and engagement in mental health services overall. Stigma in group spaces: Many group therapy and support spaces, such as Gamblers Anonymous, are open to everyone, and in their statement, mention the inclusion and support of people regardless of their marginalised identity. However, stigmas which the general public in the form of other compulsive gamblers in the same group, or those who chair the groups, may hold, could be expressed to LGBT+ participants. In vulnerable spaces, such experiences may be potentially retraumatising. In a study which conducted interviews on members of Alcoholics Anonymous, a group which shares some structural similarities with Gamblers Anonymous, LGBT+ participants reported a generally heterocentrist language being used that they found alienating, as well being victim to passive-aggression from the group leaders. [14] Whether or not the groups themselves are welcoming, fear of engaging in spaces may cause LGBT+ participants to be reluctant to engage with them. Gendered recovery spaces: Many recovery spaces are gendered, either directly (through gender-specific rehabilitation programmes) or indirectly (through a group being composed largely of one specific gender). This is likely to have negative consequences for LGBT+ people, as many people report homophobic, biphobic or transphobic experiences in single-gender spaces. Many trans people would likely be afraid to enrol in these courses for fear of facing transphobia. Furthermore, if they did apply, they may be rejected on the basis of their gender identity. Across the world, many single-gender spaces reject transgender applicants. In other support spaces, such as homeless shelters, this has occurred, leading to individuals having to go back onto the streets, or seek shelter in the housing spaces for their assigned sex at birth, which can lead to higher rates of assault and sexual abuse. Negative health outcomes are also likely to occur if someone is rejected from a rehabilitation course. Residential courses are often intensive ones, and therefore people experiencing high levels of disordered gambling for whom they may be beneficial would be either actively excluded from engaging with this mental health resource through rejection on the basis of gender identity, or passively, by facing homophobia, biphobia or transphobia and therefore not getting the same benefits as a cisgender, heterosexual participant due to the ongoing minority stress. Financial barriers. A higher percentage of LGBT+ people are unemployed, with a Stonewall report suggesting almost 1 in 5 LGBT+ people who were looking for work being discriminated against because of their sexual orientation or gender identity. [15] Issues around work also involve being fired for LGBT+ status, or experiencing workplace discrimination, including physical assaults. The TransActual 2021 study reported 63% of respondents had experienced transphobia while seeking employment, and there has been studies indicating a potential LGBT+ pay gap of up to 16%. [16] These statistics are generally also impacted by being part of a minority ethnicity in the UK, as well as disability. In countries which require specific health insurance for therapy, trans people are also less likely to be insured. [17] This means that paid-for services may be financially harder to access for LGBT+ people suffering gambling harm, making their inclusion in free services and therapies all the more critical. Recommendations for further study and improvement in standards of care Include questions about sexuality and gender identity in studies on gambling which are undertaken in the future Conduct more specific research into gambling disorders in LGBT+ communities Improve LGBT+ sensitivity training in recovery spaces, and include questions about sexuality and gender identity in intake for these spaces. Offer LGBT+ specific gambling harm reduction programmes. Include mentions of the LGBT+ specific increase in gambling risk and the potential increased risk when someone is multiple marginalised identities in early intervention and educational programmes [1] Bostwick, W. B., Boyd, C. J., Hughes, T. L., & McCabe, S. E. (2010). Dimensions of sexual orientation and the prevalence of mood and anxiety disorders in the United States. American Journal of Public Health, 100(3), 468–475 [2] Richard, J., Martin-Storey, A., Wilkie, E., Derevensky, J.L., Paskus, T. and Temcheff, C.E., 2019. Variations in gambling disorder symptomatology across sexual identity among college student-athletes. Journal of gambling studies, 35(4), pp.1303-1316. [3] https://www.mckinsey.com/featured-insights/diversity-and-inclusion/being-transgender-at-work [4] Dentato, M.P., 2012. The minority stress perspective. Psychology and AIDS Exchange Newsletter, 3. [5] Hershberger, S.L. and Bogaert, A.F., 2005. Male and female sexual orientation differences in gambling. Personality and Individual Differences, 38(6), pp.1401-1411. [6] Bush, R., Russell, A.M., Staiger, P.K., Waling, A. and Dowling, N.A., 2021. Risk and protective factors for the development of gambling-related harms and problems among Australian sexual minority men. BMC psychology, 9(1), pp.1-18. [7] Broman, N. and Hakansson, A., 2018. Problematic gaming and internet use but not gambling may be overrepresented in sexual minorities–a pilot population web survey study. Frontiers in psychology, 9, p.2184. [8] Gambling Statistics Australia February 2022: Do we have a gambling problem? (finder.com.au) [9] Birch, P., Ireland, J.L., Strickland, C. and Kolstee, J., 2015. Examining Gambling & Mental Health in LGBTI Communities: Executive Summary of Findings from a Preliminary NSW Study. [10] Gendron, T.L., Pendleton, T. and White, J.T., 2016. Mental health counseling of LGBT elders. In Handbook of LGBT elders (pp. 455-471). Springer, Cham. [11] Bockting, W., Robinson, B., Benner, A., & Scheltema, K. (2004). Patient satisfaction with transgender health services. Journal of Sex & Marital Therapy, 30(4), 277–294. doi:10. 1080/00926230490422467 [12] Ojeda-Leitner, D. and Lewis, R.K., 2019. Assessing health-related stereotype threats and mental healthcare experiences among a LGBT sample. Journal of prevention & intervention in the community, pp.1-15. [13] Trans lives survey 2021 — TransActual [14] "What Barriers to Treatment and Recovery Do LGBT Individuals with Alcoh" by April Smith (jefferson.edu) [15] LGBT in Britain - Work (stonewall.org.uk) [16] LGBT+ workers paid £6,700 per year less than straight workers, survey suggests | The Independent | The Independent [17] Full article: Healthcare Needs of the Transgender Homeless Population (tandfonline.com)

What are “skins” and “loot boxes?” Understanding loot box gambling requires an explanation of skins, a concept found in many multiplayer video games. Many games contain “skins”, aesthetically different versions of in-game items. These are most common in online multiplayer games, as rare items can be seen by other people playing the game. They can be costumes for a character to wear, weaponry which has a particular visual style, or effects that follow a character such as patterns or colours. These “skins” vary in terms of appeal both between and within games, with some items being particularly appealing to young people, such as brightly coloured guns, unicorn costumes or golden frying pans. Skins may be given to the player for completing a certain part of the game, or “unlocked” from loot boxes. Loot boxes, also known as loot crates, are items that result in a random chance of gaining a certain item from a range of available skins, with rare skins and items having low odds of being “contained” in the box. “Keys” for these loot boxes may be unlocked through play of the game, success, or commonly through purchase of keys with real currency. The items within them may be common, and have little real world value, or rare, with a high value (what we may consider a “win”). The purchase of loot box keys is not directly through real world currency in most cases, as real money must first be turned into in-game currency, and then further into keys for the boxes, before it can be used to open the box. Differences in currency values further obfuscate the true cost of the purchase. Who is playing loot box games? Many of those who play games with loot boxes are young people. The targeting of young people and children for in-app purchases and microtransactions is well-documented, and occurs in many games, particularly mobile games. Loot box or loot box-like mechanics occur in games which are particularly designed to appeal to children and young people, and which utilise popular characters and bright colours to do so. A notable example which is currently culturally relevant is Pokemon: Unite. In games which do not have particular appeal to children, there is often still a large teen or underage player base – for example, many of the people involved in the Counterstrike: Global Offensive community are underage – in one study, of 255 respondents, 46.2% of players said that they played CS:GO and were underage. [1] This, along with the ability to easily bypass age restrictions or a lack of age restrictions at all, means that many young people engage in loot box opening. Dangers of loot box gambling Many of the rarer items which may be acquired from loot boxes have high trade value, being sold on third-party trading sites for thousands of pounds. This kind of money may be especially appealing to a young person, as trading items online can be a rare source of income for a young person who may not be able to find work. Sometimes, in games such as FIFA, the unlockable items confer advantages to playing the game and are not simply cosmetic, offering another incentive to own more of them. This means that loot box opening is psychologically and operationally very similar to gambling, and has been considered as such in some of the literature surrounding it.[2] This gambling exposure has many worrying hallmarks and can have a devastating effect on players, particularly vulnerable youth players. Links have been found with gambling exposure as a youth, and gambling problems as an adult. The constant arousal associated with gambling activities leads participants in loot box gambling to require the same levels of stimulation more frequently, leading to a disordered and excessive pattern of use. Most video games analysed in one study showed most of the characteristics of gambling, and almost half of them fulfilled all criteria In one study of gamers aged 18 and over, [3] there was a strong link between loot box spending and severity of their problem gambling. This link was stronger than other common risk factors for problem gambling, such as drug abuse. In another study of 618 gamers, two thirds of those who gambled had spent money on loot boxes in the past year, and that loot box purchasing was directly related to increased problem gaming and problem gambling. [4] There is an active social network of peers which provides social incentive to gamble on loot boxes, an integration of social media channels, and the use of unrestricted purchase limits and microtransactions. Microtransactions are a particularly concerning area of gambling risk – as each purchase of a loot box is low-cost, it encourages more and more bets, and there is often no way to track how much a person has spent on loot boxes without going through several different purchase records. There are no options for self-exclusion for a player who is experiencing addiction to loot box gambling, and a player may spend far more than they are aware of. [5] Additionally, gamers who spend money on in-game purchases, spend more total money on games than those who do not. This is contrary to the idea that since many games which utilise loot boxes and microtransactions are free-to-play, there will be a balancing between the two factors. [6] Legislation surrounding loot box gambling Loot boxes lie in a grey area legally, as spending of real-world currency on the boxes is not technically “necessary” as keys can be obtained via play, and therefore the gambling is “simulated.” As the prizes are virtual, they are sometimes considered to have no value, despite the trading of items which occurs on third party sites. Another reason that loot boxes are not regulated is the assertion that no player makes a loss – they are guaranteed to contain one item, and it simply differs in rarity. However, according to studies which analysed Steam Marketplace purchases and sales of loot box items, around 93% of sales of items acquired from loot boxes recouped less than purchase price, and a rare few items accumulate immense value due to the demand. The most expensive item to ever sell in Team Fortress 2’s online trading platform, a Burning Flame Team Captain (hat), sold for approximately $14k. Players can cash out their items through third-party sites which facilitate conversion of these items, or profits from their sales, into real-world currency. The market has gone and remains unregulated in many places. The growing gap between regulation of the digital space and the activities which occur in it is visible when we see politicians and legislators state that digital items do not hold real value. This not only poses risks to young people who are engaging in gambling activities for the first time, but presents people affected by gambling harm to a novel and unregulated system which closely approximates gambling. However, there is an increased understanding of loot box gaming as something that can cause harm . in 2018, Belgium ruled that randomised loot boxes constituted illegal gambling, which means that several aspects of games are not available in the country. Some games, such as Fortnite, have removed their loot box aspect in all countries due to class-action lawsuits and campaigning to remove them; with Fortnite repaying in-store credit to anyone who had purchased their loot box-like mechanic and settling further cases with anyone who stated they had experienced harm. We believe there is a need for further review of loot box practices and the way they are implemented in video games, especially those which may have particular appeal to children, such as Pokemon Unite. Responsible gambling practices should be implemented, such as displaying the chances for each item to be acquired individually, implementing self-exclusion strategies, and allowing gamers to check how much they have spent on their gambling. [1]Beneš M. UNDERAGE GAMBLING IN COMPUTER GAMES. Proceedings New trends and research challenges in pedagogy and andragogy NTRCPA18. 2018:81. [2]Zendle D, Bowden-Jones H. Loot boxes and the convergence of video games and gambling. The Lancet Psychiatry. 2019 Sep 1;6(9):724-5. [3]Zendle, D. and Cairns, P., 2018. Video game loot boxes are linked to problem gambling: Results of a large-scale survey. PloS one, 13(11), p.e0206767. [4]Li, W., Mills, D. and Nower, L., 2019. The relationship of loot box purchases to problem video gaming and problem gambling. Addictive behaviors, 97, pp.27-34. [5]King, D.L. and Delfabbro, P.H., 2016. Early exposure to digital simulated gambling: A review and conceptual model. Computers in Human Behavior, 55, pp.198-206. [6]Drummond, A., Sauer, J.D., Hall, L.C., Zendle, D. and Loudon, M.R., 2020. Why loot boxes could be regulated as gambling. Nature Human Behaviour, 4(10), pp.986-988.

The convergence of gaming and gambling presents unique challenges for young people. The digital age means gambling is thriving, as technology can manifest in new ways with new intersections between gambling platforms and other digital media technologies. [1] What is simulated gambling? Simulated gambling is a common feature of many video games and involves an “interactive gambling activity which does not directly involve monetary gain but is otherwise structurally identical to a standard format of a gambling activity due to its wagering features and chance-determined outcomes of play”. [2] In short, the player experience is fundamentally the same as a real gambling application, except without real money being bet. In many mainstream video games, there are gambling elements, often in the style of in-game casinos one can visit. This has occurred in games across genres, including Grand Theft Auto, Fallout:New Vegas and even Pokémon. While not all representations of in-game gambling are purely positive, with more notable criticisms of casinos and gambling in some video games, such as Red Dead Redemption 2 exploring the consequences of gambling addiction on non-player characters, the game mechanics in these games where the player gambles are still designed to be “fun” for the player. To make these games of chance in otherwise skill-based games appealing, they may employ game mechanics such as a “Luck” statistic, or a minigame in which you must correctly time a button press, which can misrepresent real gambling as more skill-based than it really is. Often, the odds of winning a bet or a game in a video game are much higher than in real-life casinos or on gambling applications, which can skew player perception of gambling. In addition, in these games, players can save before each wager, and reset if they lose. Though not all representations of gambling in video games are equally addictive or positive for the player, all have the potential to cause a development in interest in gambling. Simulated gambling in video games extends to a whole genre of dedicated casino-style games, which involve no real-life transactions, but offer a similar experience to online casinos which do involve gambling. These include “free-to-play” online casinos. These simulated gambling apps are often hosted and advertised on social media, which plays into the exposure effect and social response aspect of gambling – people are more likely to engage if their peers are also involved. [3] According to Gambling Commission 2019 data using a sample of 2943 young people, 12% of 11-16 year olds have said they had played an online gambling-style game, almost half of which did so through an app. [4] These apps may be made by the same developers and owned by the same companies which develop real-money gambling applications, and indeed, the two may be one of the same, via the use of “demo modes”, a free “demonstration” of a gambling application which uses real money. Demo modes for online casinos are also a major form of youth gambling. In the same survey, 29% of young people who had gambled said they had previously used demo modes of online casinos. [5] Age checks are often not in place in online casino apps, and if they are, children may use their parent’s accounts or other methods to bypass the age restriction. Effects of simulated gambling According to research, simulated gambling exposure may be more likely to have negative consequences for youth gambling when different criteria are met. [6] Among other factors, if a simulated gambling application or game facilitates entry into a gambling subculture, providing social incentives to gamble, and encouraging covert gambling, the exposure is more likely to be considered harmful. Additionally, if the player experiences early wins, is enabled to engage in intense playstyles, and has misconceptions and false beliefs about the nature of gambling odds and skill levels, this is also harmful exposure. Simulated gambling may be beneficial as a part of gambling education if the player experiences normal win-loss outcomes and it is modelled as an educational experience with minimal extrinsic feedback. Based on these criteria, there are different levels of harmful exposure in video games; and the worst offenders are the dedicated casino-style gambling applications, which often exhibit skewed outcomes that favour the player and are designed to encourage players to keep playing in order to make money, either because they rely on making money through advertising or because they are closely linked to true gambling applications. Though the simulated gambling in more mainstream video games meets less of these criteria, and there are opportunities for gambling experiences to be more educational in these regards, we believe that exposure in some video games may have an overall negative effect. According to the ESRB‘s (Entertainment Software Rating Board) criteria, simulated gambling mechanics are considered appropriate for players aged 13 and up. We believe that this is unsatisfactory, as the links between simulated gambling and gambling behaviours with real money should not be downplayed. Gambling in real life situations has a much higher age limit, and exposure of adolescents, especially in situations where they feel compelled to gamble in these simulated environments, is likely to result in later issues for some people. [7] For more information on gambling in video games and its effects, please read our pieces on loot boxes and on online skin betting. [1]King D, Delfabbro P, Griffiths M. The convergence of gambling and digital media: Implications for gambling in young people. Journal of Gambling Studies. 2010 Jun 1;26(2):175-87. [2]King, D.L., Delfabbro, P.H., Kaptsis, D. and Zwaans, T., 2014. Adolescent simulated gambling via digital and social media: An emerging problem. Computers in Human Behavior, 31, pp.305-313. [3]Armstrong, T., Rockloff, M., Browne, M. and Li, E., 2018. An exploration of how simulated gambling games may promote gambling with money. Journal of Gambling Studies, 34(4), pp.1165-1184. [4]Young People Gambling Report 2019 (cliftondavies.com) [5]Wood RT, Griffiths MD. A qualitative investigation of problem gambling as an escape‐based coping strategy. Psychology and Psychotherapy: theory, research and practice. 2007 Mar;80(1):107-25. [6]King, D.L. and Delfabbro, P.H., 2016. Early exposure to digital simulated gambling: A review and conceptual model. Computers in Human Behavior, 55, pp.198-206. [7]Kushner, M., Thurus, P., Sletten, S., Frye, B., Abrams, K., Adson, D., Van Demark, J., Maurer, E. and Donahue, C., 2008. Urge to gamble in a simulated gambling environment. Journal of Gambling Studies, 24(2), pp.219-227.

Pupils at Fairfield Church were the beneficiaries of the 'Preventing Gambling Harm in Diverse Communities' initiative on Wednesday 20th April 2022. A small but engaging workshop where another 11 students learnt about gambling harm. Jack Baker, the organiser of the delivery, was delighted to get Gambling Harm UK in to teach the attendees about gambling harm, and we were excited to do so. It is essential to bring this message across to places of worship, and we took a step in doing so today. Thank you, Fairfield Church, for having us.

On the Monday 21st March 2022, I was humbled to deliver the 'Preventing Gambling Harm in Diverse Communities' initiative to Park Academy West London, a partner school of a previous workshop we had completed to River Academy West London. River Academy West London welcomed me with open arms, and the reception was matched from Park Academy West London. I was delighted to deliver our project to just over 390 students on the day ranging from the years 9-11. A lot was learnt on both sides, I was asked engaging and thoughtful questions, and I hope I provided the children with enough information to impact their lives. Thank you to each attendee, your efforts to grasp vital knowledge on this subject were appreciated.

Our long-awaited delivery to Bishop Ramsey Church of England School was successfully completed on Friday 4th March 2022. Dani Williams who organised the programme and delivery of the 'Preventing Gambling Harm in Diverse Communities' initiative, was one of our earliest bookings. When we were new to this area, I was thrilled to find that Dani was willing to learn more about gambling harm, and she showed a keen interest in enlightening students at the school she teaches. This allowed us to arrange this school booking six months in advance. Despite some technical difficulties on the day, each of the 150 students took away vital solutions to preventing gambling harm and gained in-depth knowledge on the subject. I was pleased to be at the forefront of this, and I hope to have a more significant impact on the rest of the school. Thank you, Bishop Ramsey, for believing in Gambling Harm UK and our work.

On Monday 21st February 2022, Joshua Palmer and Ben Jones from Red Card were welcomed by Aldenham School in Borehamwood. We were invited to speak to pupils from the school years of Year 7 through to Year 13 by Jos Perris, the Reverend of the Chapel attached to the school to deliver the 'Preventing Gambling Harm in Diverse Communities' programme. A wonderful, with thought-provoking questions, attentive students, and engaged teachers, which saw us deliver to just under 680 students. Thank you, Aldenham School, for your support in our programme, for recognising the significance of gambling harm on young people and allowing us to come in to deliver our free specialist workshops to the students.