Implications for Public Health - Springer Link

Int J Ment Health Addiction (2009) 7:3–11 DOI 10.1007/s11469-008-9189-6

The Use of Social Marketing to Influence the Development of Problem Gambling in the UK: Implications for Public Health Jane E. Powell & Alan J. Tapp

Received: 26 May 2008 / Accepted: 12 December 2008 / Published online: 20 December 2008 # Springer Science + Business Media, LLC 2008

Abstract In this paper the authors present and debate the theoretical case for the use of social marketing to help reduce problem gambling in the public health context of the UK. Is triangulated between the key theories and principles of social marketing, the key literature and its theoretical application to the debate about reducing problem gambling in the UK. The distinctions between social marketing and health education are outlined. Exchange theory, relationship marketing, and consumer focus and insight are vital to work with the public health implications of problem gambling. Social marketing may have something to offer problem gamblers, professionals in public health and policymakers. However, the self interest of the problem gambler should strongly guide intervention programmes. Such programmes should be designed with the ideal of building relationships such that long term behaviour change is effected. Keywords Social marketing . Gambling . UK . Public health

Introduction Gambling in the UK is associated with high rates of participation compared with other countries, recent changes in legislation, and a recent increase in the number and nature of gambling products. Despite these changes, the idea that gambling is a public health issue has yet to gain full acceptance in the UK (Orford 2005). In this paper we address the proposition that social marketing techniques may be useful in minimising the prevalence of problem gambling in the UK.

The Current Context for Gambling in the UK The term ‘problem gambling’ tends to be used imprecisely to describe the myriad of ways in which non-pathological gamblers run up debt through out-of-control gambling. Precise J. E. Powell (*) : A. J. Tapp University of the West Of England, Bristol, UK e-mail: [email protected]

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Int J Ment Health Addiction (2009) 7:3–11

measures of problem gambling include the DSM IV (using a threshold of three) (American Psychiatric Association 2000) and the Canadian Problem Gambling Severity Index (PGSI) (using a threshold of 8) (Wynne 2003). Despite high participation rates of 68 per cent in all gambling forms, the recent ‘British Gambling Prevalence Survey’ demonstrated that the UK has one of the lowest ‘problem gambling’ prevalence rates in the developed world, with about 0.6 per cent (DSM-IV) and 0.5 per cent (PGSI) of the population currently identified as problem gamblers, respectively (Wardle et al. 2007). This population survey was based on a random sample of 9,003 British people and mirrors the prevalence rate found in a previous survey in 1999 (Wardle et al. 2007). The stability of these findings demonstrate the existence of socio-cultural elements in UK culture which regulates ‘out of control’ gambling, despite the fact that 68 per cent of the British population, that is about 32 million adults, had participated in some form of gambling activity within the past year (Wardle et al. 2007). While the UK picture remains stable at present, worldwide, the internet looks to be a major engine of future gambling growth and an attendant increase in problem gambling. Currently, some 6 per cent of people use the internet to gamble, but this figure is certain to rise significantly in the near future. The same issues have been strongly debated in Australia (Dowling et al. 2005) and the United States (Whyte 1999).

Recent Gambling Policy Changes Gambling has become a hot topic in the UK, as new laws for the de-regulation of gambling advertisements came into effect in September 2007. A new pro-industry governmental stance that sees gambling and gaming as part of leisure activity will extend the availability of opportunities to gamble, and allow gambling operators to advertise on television for the first time. Notably, the first adverts to appear on television since the deregulation of gambling advertisements have sought to position gambling activity as a social norm, highlighting the activity as something that is both popular and fun. In addition to advertising, more lenient laws regarding the building of gambling casinos in towns and cities across Britain, and government proposals to regenerate deprived areas economically by awarding licences to gambling service providers have also contributed to change in the gambling climate in the UK. According to previous government plans, gambling service providers and property developers had plans to build super casinos in which the local population might gain employment. These plans were abandoned by Gordon Brown within a week of his becoming prime minister, presumably because he had some personal difficulty with such notions of ‘regeneration’. Other researchers have examined the prevalence of excessive gambling before and after the introduction of policy changes, for example, the national lottery in the UK in 1992. They have demonstrated that gambling is another example of Geoffrey Rose’s single distribution theory (Grun and McKeigue 2000). Rose advocated a single distribution theory of populations with his proposal that for any characteristic distributed in the population, in this case excessive gambling, that the proportion of excessive gamblers in the tail of the population distribution of gambling depends upon the average level of gambling behaviour in the population as a whole (Rose 1985; Rose 1992). Grun and McKeigue concluded from their analysis of the national Family Expenditure Survey data, before and after the introduction of the UK national lottery, that the increase in average gambling expenditure has led to a pronounced increase in the prevalence of excessive gambling, defined at household level as spending more than 10 per cent of household


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income per week on gambling in low-income households (Grun and McKeigue 2000). The single distribution theory implies that policies that aim to control individuals who gamble excessively at the tail end of the distribution of gambling behaviour will have limited success if the whole probability distribution is moving in the direction of the tail. Rose’s single distribution theory predicts that that any policies that increase the average level of gambling will inevitably increase the prevalence of excessive gambling in the entire population. This has serious implications for public health in the UK, as excessive problem gambling is associated with high rates of suicide attempts, domestic violence and crimes to finance gambling addictions (Bland et al. 1993).

Behaviour Change Problem gambling is often addressed through health education, legislation, or a mixture of both, in sub-groups of the population deemed to be at risk. However, health education seems to have had limited success. For instance, this quote from Poulin (2006) sums up the issue:The third elephant has to do with health promotion. It is time for governments and public health advocates to stop being seduced by the promise of anti-gambling campaigns and education that place the onus of self-control on the shoulders of the very individuals who have a serious disorder of impulse control. Rather, we should apply what has been learned from tobacco control strategies—success is achieved primarily through public policy. (Poulin 2006, p. 1) Attempts have been made in many parts of the world to move away from health education towards more persuasive approaches, such as health advertising (Perese et al. 2005). In 2004, the gambling charity GamCare launched the first public health advertising campaign in Great Britain that warned citizens of the dangers of problem gambling. But health advertising on its own has a dubious record of success. In the US state of Indiana, a statewide advertising campaign designed to increase awareness of problem gambling led to disappointing results, with little success in reaching their target audience, and ultimately having very little effect on modifying gambling behaviours (Najavits et al. 2003). It has been argued that upstream interventions in the form of legislation can be more effective in changing problem behaviour than health education. The UK ban on advertising has led to low rates of gambling, a result that has been mirrored in other countries (Dowling et al. 2005; Whyte 1999). For instance, the adverse effects of gambling have been minimised in Western Australia, compared to other states and territories in Australia, due to strict policies that limit the availability of electronic gaming machines (Howat et al. 2005). However, legislation can be divisive and difficult to implement in democratic regimes, with the gambling industry backed by a powerful ‘freedom to choose’ philosophy. An alternative that allows for the preservation of democracy, while still promoting the dangers of problem gambling is the use of social marketing techniques.

Social Marketing of Gambling Social marketing is the use of marketing techniques to enable behaviour change for social good. Social marketing’s roots go back to the 1950s with Wiebe’s famous quote (Wiebe

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1952) ,‘why can we not sell brotherhood in the same way as we sell soap’? (Wiebe 1952, p. 443) This idea was taken forward and launched as a sub-discipline of academic marketing by Kotler and Zaltman (1971). Since those pioneering days, social marketing has grown into a reasonably well established discipline, and has been used successfully to reduce risky behaviours such as smoking and heavy drinking, in addition to encouraging positive health behaviours such as the use of sun screen products and safe driving practices (Hastings 2007). However, just because social marketing has worked in other contexts, does not necessarily mean it will succeed in reducing problem gambling. Indeed, as yet, there are very few practical examples to help us support such a position. One exception was reported by Korn et al. (2006), who described a youth oriented website called YouthBet.net. YouthBet.net featured games, information and other resources to help protect youth from gambling-related harm. A youth working group spent several months designing the look and feel of the site, and research on the site suggested that youth participants liked the interactive way gambling information was presented through realistic games and quizzes. Meanwhile, in line with the recent de-regulation of gambling advertisements, the Responsibility in Gambling Trust of Great Britain is, at the time of writing, launching a web site as part of a national program to raise awareness of problem gambling. But, while encouraging, these sites are exceptions and illustrate the paucity of social marketing practice in this arena. To expand the usage of social marketing, we require a set of core principles that will help us demonstrate the usefulness of social marketing as a means to reduce problem gambling. We also need to be clear in distinguishing social marketing from health promotion or health education. Some may argue that the YouthBet website above is an example of the latter, so clarification of overlaps and differences is helpful.

Applying Social Marketing Principles to Problem Gambling A series of principles can help us. Firstly, there is now a general recognition that social marketing should focus on changing behaviour (Andreasen 2000). If behaviours are changed—quitting smoking, eating more healthily, increased recycling—then social marketing is deemed to have been successful. If the intention is to persuade problem gamblers to reduce their gambling to acceptable levels, or to give it up altogether, then this behaviour change may be an appropriate objective for social marketing. Secondly, at the extreme, some health education or promotion has been criticised as being an approach which starts with the point of view of health professionals and takes little account of the mindset of the target audience. In contrast, the first guiding principle of social marketing is to start with the customer or citizen: What is their everyday life like? What problems do they face? Why are they gambling so heavily? Have they tried to give it up, and what has stopped them from doing so? For example, one of the authors has recently been involved in a qualitative study that sought to understand the influence of class based socio-cultural forces on lifestyle decisions that social marketers wish to affect (Spotswood and Tapp 2008, unpublished). The first findings from this study (due to be submitted to a journal) found that social class cultures were of great potential importance in understanding many social marketing issues. This certainly seems to be the case for gambling, with lower socio-economic groups confirmed as more likely to be problem gamblers across a number of studies, in different countries


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including Singapore (Teo et al. 2007), the UK (McKee and Sassi 1995) (The British Gambling Prevalence Survey 2007; Wardle et al. 2007), and the USA (Volberg 1994). Spotswood and Tapp (2008) describe middle class people as no longer being constrained by ‘modernist’, pre-ordained, rule bound lives, but instead are free to choose from an ever expanding menu of lifestyles and personal codes to guide their behaviour. Such people, with their wide horizons and confident choices from a vast range of activities, lifestyles and identities, contrasted starkly with ‘working class’ respondents interviewed in deprived areas. These respondents’ basket of activities was sharply limited by their local environment and by what was seen as culturally acceptable. Their environment was physically and socially ‘sealed off’ and slow to change—so doing new things was discouraged. To add to the isolation, it quickly became clear that less well off interviewees had far less bridging (long distance across community divides) social capital than middle class interviewees, resulting in ‘hermetically sealed communities’. Some interviewees suggested that the community had become so closed as to produce their own rules and social order. It was also found that the low perceived self efficacy to improve their health through exercise appeared to reflect a fatalistic attitude to their lives in general, one where control of their destinies was handed over to external factors or ‘chance’. Many of these findings seem relevant to reducing problem gambling in deprived communities. The lack of confidence to control one’s own life, the lack of culturally acceptable alternative activities, and the lack of bridging social capital to enable people to picture alternative ways of living, all conspire to drive individuals to behave according to locally driven notions of what is culturally acceptable. These findings—from another sphere of social marketing—suggest macro culture changes are often necessary to supplement personal responsibility to effect individual level behaviour change. The British Gambling Prevalence Survey (2007) findings on cultural attitudes to gambling in the UK found agreement that there was a right to gamble and rejected total prohibition. But the prevalence of gambling problems in lower income households suggests a community level, as well as individual level problem that will require community level solutions in addition to those tailored to indivduals.

Contrasting Social Marketing with Health Education: The Principle of Exchange The most fundamental differences between health education and social marketing lie in the conceptualisation of the two disciplines. Rothschild (1999) explained how the tripartite classification between education, marketing and law was originally developed by Lindblom (1977), an economist who identified education, exchange and authority as the mechanisms of social control. According to this framework, education refers to messages, of any type, that attempt to inform and/or persuade the target to behave in a particular way, without the promise of reward or the threat of punishment. For example, a simple message, such as ‘quit gambling before it’s too late’ would fall under this remit. It should be noted that education can suggest an exchange for a benefit—such as, “quitting gambling will save you $100 a month”—but it cannot deliver the benefit of the exchange explicitly. In contrast, the central concept of marketing is regarded by many as exchange (Kotler and Zaltman 1971; Rothschild 1999). In social marketing, social objectives are achieved by offering a benefit in return for voluntary behaviour change. The need to offer a benefit stems from Rothschild’s assertion that ‘people act primarily out of self interest’. These benefits may be offers to the customer that—sometimes crucially—may be in the form of

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something tangible and immediate, as well as the long term benefit of the behaviour change itself. These may be quite simple: strips of cloth given to women in Bangladesh to strain their drinking water reduced cholera by 50%. A ‘gambling cessation service’ that provides an attractive (nurturing and supportive) social environment within which problem gamblers can be helped to quit, would perhaps be one approach. A straightforward incentive may be another example. For example, Rothschild’s (Rothschild et al. 2006) RoadCrew service controversially offered subsidised driving services to heavy drinkers in Minnesota in order to reduce the incidence of drinking and driving in the state. The equivalent would be to offer tangible incentives to problem gamblers in order to motivate them to quit. This may be ethically debatable, and possibly economically or practically unfeasible, but it does highlight another way in which social marketing differs from health education by highlighting how self interest can motivate the behaviours of target citizens. The picture painted so far of social marketing is, we hope, useful for professionals addressing problem gambling, but reflects a (US led) view of marketing as being dominated by the ideas of exchange, transaction and self interest. We can now address some additional features of marketing that have been adopted by social marketers. One of the primary writers in social marketing is Andreasen whose six point social marketing process for behaviour change (Andreasen 2000) has been adapted by the UK National Social Marketing Centre (a government sponsored body) into an eight point set of benchmarks: Table 1: The UK National Social Marketing Centre Eight Benchmarks for Social Marketing 1. Customer Orientation 2. Focus on behaviour 3. Use of behavioural theory 4. Generation of customer insights that help programme design 5. An emphasis on exchange—costs and benefits to the consumer 6. A competition analysis that recognises threats to the desired change 7. A segmentation approach 8. A mix of methods deployed as an ‘intervention’.

Without labouring through these points, we can usefully highlight how additional key marketing concepts can be deployed in the problem gambling context. We have already noted how social marketing starts from the point of view of the customer, and the realities of their everyday lives, rather than from the point of view of the ‘experts’. Another way to engender this focus is by segmenting the target audience. The use of segmentation is often vital for successful social marketing outcomes, and may also help us identify profiles of likely problem gamblers. Another advantage to sub-segmenting is that by dividing problem gamblers into discrete groups, we are better able to recognise how different types of people may be problem gamblers for different reasons. In turn, such an analysis leads to tailored solutions that fit the needs of a greater range of problem gamblers. This is known as ‘benefit segmentation’. Key benefits accrued from gambling include making money, excitement/mood change, and opportunities to socialise with other people. Since problem gamblers tend to take one or more benefit to the extreme, each ‘benefit’ can then be counteracted using different social marketing techniques. For example, the mistaken belief that gambling is profitable may be countered through communication approaches similar to the Florida based ‘Truth’ campaign (Hicks 2001). The “Truth” campaign featured detailed information about the tobacco industry, and their attempts to make smoking look ‘cool’, particularly to young adults and teenagers. The campaign was recognized as a


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success, as it did have some effect on reducing smoking. With respect to excitement/mood changes, or socialisation benefits sought by problem gamblers, these benefits may be countered with individual level interventions that offer alternative sources of excitement or socialisation in exchange for eliminating problem behaviours. Another notable social marketing principle is competition. Competition analysis identifies psychological and external drivers that lead to behaviours that compete with the desired change. Gambling involves pleasurable risk taking, thrill seeking, the euphoria of winning, and the temptation of easy money. Externally, the gambling industry is busily marketing its services in attractive ways, making the social marketers job that much more difficult. The use of marketing techniques to reduce problem gambling is very apposite within the authors’ UK home, given the very recent deregulation of advertising to encourage gambling. Interestingly, a recent advert for betting firm Ladbrokes clearly focused on creating the impression that gambling is part of everyday, normal behaviour— further evidence of the importance of cultural norms in this battleground. A somewhat ironic possible scenario in the UK is that marketing as a discipline may be a prime mover in both encouraging gambling amongst the wider populace, and simultaneously discouraging gambling amongst its most vulnerable groups. That being said, the Gambling Commission has insisted operators adopt a code of practice on social responsibility in advertising, demanding that all work includes a link to a website on responsible gambling, and the inclusion of other socially responsibility messages in their advertising and sponsorship activity (GamCare[online] 2008). The eight point benchmarks described above are helpful, but may be selling social marketing a bit short. The (arguably European dominated) school of Relationship Marketing is considered by influential writers (for example Hastings 2007) to be particularly applicable to social marketing. The direction of the US social marketing literature can be criticised as concentrating too much on discrete model components—self interest and the transaction— and not enough on macro socio-cultural effects. In reality, social marketing’s goal is rarely to change the behaviour once (Hastings 2007). As Hastings explains, “We do not want people to wear a seat belt once, refrain from hitting their partner every now and then or eat five portions of fruit and vegetables occasionally. We want them to do these things again and again—indeed forever more. Actually our interest is very often in lifestyles rather than isolated behaviours”. (Hastings 2007, p. 129) The idea is that by developing long term relationships with clients, the chances of successful long term behaviour changes are maximised. This suggests that social marketing should integrate with the kind of community development programmes that public health professionals have long championed. Orford in his ‘For Debate’ article, entitled “Disabling the public interest: gambling strategies and policies for Britain”, adds his voice to those concerned about protecting children and young adults, and urges the government to see gambling dependence as a public health issue (Orford 2005).

Conclusion: A Future for Social Marketing in Reducing Problem Gambling? Reducing problem gambling is difficult. Problem gamblers are often living unsatisfactory lives and lack the kind of wealth, work or extra-work activity rewards that professional people may take for granted. Gambling affords a thrill, an escape from humdrum everyday realities, and is fuelled by the mistaken belief that gambling is profitable, and a means to solve one’s financial problems. Arguably, health education on its own is limited in what it

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can achieve with respect to changing problematic gambling behaviours. What makes social marketing so compelling is that it starts with reality, as perceived by the client, and understands that any intervention must emerge from that reality. The self interest of the problem gambler should strongly guide the intervention—with a recognition that their self interest may well differ from pre-conceived notions held by otherwise well meaning professionals. An offer of some sort—a proposition—could be made in which a trade off may be sought with the gambler in return for behaviour change. Furthermore, the programme should be designed with the ideal of building relationships, such that long term behaviour change is effected. It is hoped that these ideas are of interest to professionals wishing to add to the armoury of health education or legislation.

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