Commentary on Heirene & Gainsbury: Re-thinking prevention in the gambling field through applying the triad universal, selective and indicated preventions.

Abstract

Re-thinking the prevention of gambling-related harms by applying the triad of universal, selective and indicated prevention approaches could better target initiatives to populations. Heirene & Gainsbury promote an indicated prevention approach to encourage limit-setting, and targeting this to an appropriate time in the gambling course could optimize its acceptability by operators and effectiveness. Alcohol and substance use disorder fields tend to conceptualize prevention as ‘universal’ (offered to the whole population), ‘selective’ (targeting subpopulations with biological, psychological and/or socio-cultural risk factors) and ‘indicated’ (targeting people who are engaging in hazardous behaviours and have precursors or symptoms of substance use disorder) [1-4]. Indicated prevention programmes seek to refer people to appropriately matched brief or more intensive treatment interventions. The gambling field has developed its own prevention framework using the concept of ‘responsible gambling’ [5]. Responsible gambling was developed as a harm reduction approach to accommodate the divergent interests of gambling stakeholders, and is similar to very early models of alcohol harm reduction [6]. As discussed by Heirene & Gainsbury [7], contemporary responsible gambling approaches typically promote ways in which people can use tools to set limits to their wagering or self-exclude from gambling altogether. These are usually implemented through a selective prevention approach, although there is passive targeting of all gamblers. There is evidence that gambling operators assume that these prevention measures are sufficient [8]. However, additional prevention interventions providing information and better decision-making have been proposed to target causal, frequent and intensive gambling groups [9, 10]. Re-thinking prevention in the gambling field via a triad of universal, selective and indicated preventions could guide existing and future prevention initiatives in gambling, personalized to the targeted population. For instance, some tools could be more relevant in an indicated approach, targeting gamblers who have impairments in cognitive control. Self-exclusion is a good example, because previous research suggests that this action mainly appeals to people with a gambling disorder [11-13]. Nevertheless, it is still considered as a responsible gambling tool in a selective prevention approach for all gamblers. Developing self-exclusion in an indicated approach would provide the opportunity to proactively propose self-exclusion to highest risk gamblers, screened using validated tools, and further involve them in dedicated therapeutic interventions when needed. In their study [7], Heirene & Gainsbury tested a proactive message promoting limit-setting to all gamblers without a limit set (i.e. a group with a risky gambling pattern of use, placing their intervention in a proactive and selective prevention approach). An important finding was that the largest predictor of limit-setting was having previously set and then removed a limit. People who remove previous set limits will probably do so because either the limit was too low or because they are now experiencing symptoms of gambling disorder (GD) [14]. Further, this finding suggests that proactive limit-setting after the initial period of gambling on an operator's website could be effective in an indicated prevention approach for people with early symptoms of GD. The fact that once a responsible gambling tool is used it is more easily re-used supports previous findings on self-exclusion [15]. Heirene & Gainsbury discuss their findings in the light of previous data targeting gamblers with hazardous behaviours [16]. Although we should recognize that gambling operators may be resistant to displaying messages repeatedly so that their products have less appeal [6], there are important opportunities to further develop this approach to help prevent gambling-related harm. The triad of indicated, selective and universal prevention provides the opportunity to optimize effectiveness, feasibility in real life and acceptability of interventions. None.