A systematic review of educational programs and consumer protection measures for gambling: an extension of previous reviews

Figures & data

Table 1. Inclusion and exclusion criteria for gambling prevention/educational programs.

Scope	To investigate the effectiveness of gambling prevention/educational programs
Participants	≥13 years of age. Studies with younger participants were included if ≥75% of the participants were 13 years or older, or if they reported results separately for relevant age. Studies where ≥75 % of the participants had severe gambling problems (e.g. Problem Gambling Severity Index, PGSI ≥8) were excluded.
Intervention	Education Excluded: information activities without a specific target group.
Control	None or any types of intervention
Outcome	Primary outcome: gambling frequency and gambling problem. Secondary outcomes: gambling knowledge and attitudes.
Study design	Randomized controlled trials (RCT) and non-randomized study (NRS) with at least 20 participants in each group.
Follow up	Primarily studies with at least 6 months follow up in accordance with Society for Preventive Research recommendations. However, studies with 1 month follow up were accepted.

Table 2. Inclusion and exclusion criteria for responsible gambling strategies.

Scope	The effectiveness of responsible gambling strategies
Participants	≥16 years of age. Studies with younger participants were only included if ≥75% of the participants were 16 years or older or if they reported results separately for relevant age. Studies where ≥75 % of the participants had severe gambling problems (e.g. Problem Gambling Severity Index, PGSI ≥ 8) were excluded, exception for studies evaluating self-exclusion programs
Intervention	Responsible gambling strategies such as pop-up messages, self-exclusion program, normative personalized (normative) feedback, limits
Control	A control was not required to be included in the review
Outcome	Primary outcome: gambling frequency measured with time or money and self-reported gambling problems
Study design	Randomized controlled trials (RCT) and non-randomized study (NRS) with at least 20 participants per group. For studies lacking a control group the number of participants had to be ≥100. Studies without control (cohorts) with ≥50% drop out were excluded. Studied with a drop out between 30 and 50% were discussed by the whole group. Case control studies were excluded.
Follow-up	No restriction

Figure 1. Flow chart of the from the search results.

Figure 2. (a) RCT and NRS with critical or high risk for bias. (b) Cohort studies with critical or high risk for bias.

Table 3. Characteristics of studies with low or moderate risk of bias regarding educational program strategies.

Study design, Country reference	Intervention	Population	Outcome	Follow up	Included in meta-analysis
Canale 2016 RCT, Italy Canale et al. (2016)	Education, school, longer program	14–18 years of age n = 168	Gambling problem, gambling frequency, loss/bets attitudes	2 months	Gambling frequency
Donati 2014 RCT, Italy Donati et al. (2014)	Education, school, longer program	14–18 years of age n = 91	Knowledge, attitudes	6 months
Lupu 2013 RCT, Romania Lupu and Lupu (2013)	Education, school, longer program	12–13 years of age n = 75	Knowledge	6 and 12 months
St-Pierre RCT, Canada St-Pierre et al. (2017)	Education, school, short program	13–18 years of age n = 280	Gambling frequency/attitudes	3 months
Turner 2008 RCT, Canada Turner et al. (2008)	Education, school, longer program	13–18 years of age n = 201	Knowledge	2 months
Williams 2010 RCT, Canada Williams et al. (2010)	Education, school, longer program	13–20 years n = 1686	Gambling Problems, gambling frequency, loss/bets, knowledge, attitudes	4 months	Gambling frequency
Williams 2006 NRS, Canada Williams and Connolly (2006)	Education, college, focused on probability	College students n = 300	No of gamblers, gambling frequency, bets, attitudes, knowledge	6 months
Doiron 2007 RCT, Canada Doiron and Nicki (2007).	Program stop and think!	Gamblers Mean age: 38 years Men = 60% n = 40	Money spent, hours played/no of sessions, gambling behavior	1 months

Table 4. Summary of finding for educational program (long) compared to no intervention.

Outcome	Follow-up	Participants (no of studies)	Results	GRADE	Comments
Changes in gambling problems, SOGS-RA	2 months	168 (1 RCT) Canale et al. (2016)	MD: −0.19 (95%CI −0.37, −0.01)	Very low ⊕ΟΟΟ	–One bias^a –Two imprecision^b
Proportion of persons with gambling problems	4 months	659 (1 RCT) Williams et al. (2010)	RD: −0.02 (95%CI −0.05, 0.01)	Very low ⊕ΟΟΟ	–One bias^a –Two imprecision^c
	4 months booster	390 (1 RCT) Williams et al. (2010)	RD: 0.04 (95%CI 0.00, 0.07) RR: 0,31 (95%CI 0.09, 1.10)	Very low ⊕ΟΟΟ	–One bias^a –Two imprecision^c
Gambling frequency (number of days gambling)	2–4 months	827 (2 RCT) Canale et al. 2016; Williams et al. (2010)	SMD: −0.29 (95%CI −0.48, −0.11)	Low ⊕⊕ΟΟ	–One bias^a –Imprecision^d –Inconsistency^e
Gambling frequency (number of days gambling/90 days)	4 months booster	390 (1 RCT) Williams et al. (2010)	MD: −10,66 (95%CI −15.46, −5.86) reduction	Very low ⊕ΟΟΟ	–One bias^a –Two imprecision^c
Bets	2 months	168 (1 RCT) Canale et al. (2016)	No statistically significant difference	Very low ⊕ΟΟΟ	–One bias^a –Two imprecision^b
Losses	4 months	659 (1 RCT) Williams et al. (2010)	No statistically significant difference	Very low ⊕ΟΟΟ	–One bias^a –Two imprecision^c
	4 months booster	390 (1 RCT) Williams et al. (2010)	No statistically significant difference	Very low ⊕ΟΟΟ	–One bias^a –Two imprecision^c
Knowledge (different scales used). Not possible to merge in meta-analysis)	2 months	201 (1 RCT) Turner et al. (2008)	MD: 17.00 (95%CI 12.53, 21.47)	Very low ⊕ΟΟΟ	–Two indirectness^f –Two imprecision^b
	4 months	659 (1 RCT) Williams et al. (2010)	MD: 0.89 (95%CI 0.67, 1.11)	Very low ⊕ΟΟΟ	–One bias^a –One imprecision^h –Two indirectness^f
	6 months	147 (1 RCT) Donati et al. (2014)	No statistical difference	Very low ⊕ΟΟΟ	One small study without significant results
	6 months 12 months	75 (1 RCT) Lupu and Lupu (2013)	MD: 11.58 (95%CI 9.45,13.71)	Very low ⊕ΟΟΟ	–One bias^g –Two imprecision^b –One indirectness^h
			MD: 12.39 (95%CI 10.26, 14.52)
Attitude (different scales used)	2 months	168 (1 RCT) Canale et al. (2016)	MD: −1.97 (95%KI −4.06, 0.12)	Very low ⊕ΟΟΟ	–One bias^a –Two imprecision^b –Two indirectness^f
	4 months	659 (1 RCT) Williams et al. (2010)	MD: −0.54 (95%CI − 0.77, −0.31)	Very low ⊕ΟΟΟ	–One bias^a –One imprecision^h –Two indirectness^f
	6 months	147 (1 RCT) Donati et al. (2014)	No statistical difference	Very low ⊕ΟΟΟ	One small study without significant results

Note: CI: confidence interval; MD: mean difference; SMD: standard mean difference; RD: risk difference.

^aDrop out >20%.

^bVery few participants.

^cWide CI and only one study.

^dWide CI.

^eInconsistency among the programs.

^fUsed scales that did not measure gambling problems and short follow up (indirectness).

^gUnclear how the randomization was carried out.

^hOne study with limited number of participants.

Table 5. Summary of findings for educational program (short) compared to no intervention.

Outcome	Participants (no of studies) Reference	Results MD (95%CI)	GRADE	Comments
Attitudes (GAS, 12 items, score 12 − 60)	280 (1 RCT) St-Pierre et al. (2017)	MD: −0.96 (−2.54, 0.62)	Very low ⊕ΟΟΟ	One small study without significant results
Gambling Activities Questionnaire (max score 44)		MD: −0.24 (−2.43, 1.95)	Very low ⊕ΟΟΟ	One small study without significant results

Note: CI: confidence interval.

Table 6. Characteristics of studies with low or moderate risk of bias regarding consumer protection interventions.

Study design, country Reference	Intervention	Population setting	Outcome	Follow-up	Included in meta-analysis
Auer 2016 RCT, UK Auer and Griffiths (2016)	PNF		Theoretical loss	6 months
Celio 2014 RCT, USA Celio and Lisman (2014)	PNF	Laboratory setting	Gambling frequency, theoretical loss	Instantly after intervention
Cunningham 2012 RCT, Canada Cunningham et al. (2012)	PNF PF	Gamblers	Gambling frequency, theoretical loss	3, 6 and 12 months	Gambling frequency, theoretical loss
Martens 2015 RCT, USA Martens et al. (2015)	PNF	College	Gambling problem, gambling frequency, theoretical loss	3 months	Gambling problem, gambling frequency
Neighbors 2015 RCT, USA Neighbors et al. (2015)	PNF	College	Gambling problem, gambling frequency theoretical loss	3 and 6 months	Gambling problem, gambling frequency, theoretical loss
Wood 2015 NRS, Canada Wood and Wohl (2015)	PF	Problem gambling	Theoretical loss	6 months
Auer 2015 Cohort, UK Auer and Griffiths (2015)	PNF PF	Adults	Proportion of gamblers ending their online gambling session/slots	Instantly after intervention
Broussard, 2017 RCT, USA Broussard and Wulfert (2017)	Pop-up	Laboratory setting, college students, slots	Gambling frequency: no. of spins	Instantly after intervention	Gambling frequency: no. of spins
Floyd 2006 RCT, USA Floyd et al. (2006)	Pop-up	Laboratory setting, college students, roulette	Time spent gambling, bets	Instantly after intervention	Time spent gambling, bets
Ginley 2016 RCT, USA Ginley et al. (2016)	Pop-up	Laboratory setting, college students, slots	Gambling frequency: no. of spins	1 week	Gambling frequency: no. of spins
Jardin, 2012 RCT, USA Jardin and Wulfert (2012)	Pop-up	Laboratory setting, experienced gambler	Time spent gambling, bets	Instantly after intervention
Rockloff, 2015 RCT, Australia Rockloff et al. (2015)	Pop-up	Laboratory setting, gamblers without experience	Bets	Instantly after intervention
Steenbergh 2004 RCT, USA Steenbergh et al. (2004)	Pop-up	Laboratory setting, college students, roulette	Time spent gambling, bets	Instantly after intervention	Time spent gambling, bets
Kim 2014 RCT, Canada Kim et al. (2014)	Pop-up: Limitation in money	Laboratory setting, College students n = 43	Time spent gambling	Instantly after intervention
Wohl 2014 RCT, Canada Wohl et al. (2014)	Pop-up: Limitation in time	Laboratory setting, college students n = 56	Proportion of gamblers who didn’t exceed their limit regarding time	Instantly after intervention
Auer 2013 Cohort, Austria Auer and Griffiths (2013)	Limits in money and time	Online	Theoretical loss, gambling frequency	1 months
Nelson 2008 Cohort, USA Nelson et al. (2008)	Limits in money and time	Online	Loss	6 months
Sharpe 2005 NRS, Australia Sharpe et al. (2005)	Limits in time: Slots with different limits	Hotel and pubs,	Time spent gambling, bets, net loss	Instantly after intervention
Caillon, 2019 RCT, France Caillon et al. (2019)	Self exclusion 1 week	18% with gambling problems n = 60	Money, time spent gambling	14 days, 2 months
McCormick 2018 Cohort, Canada McCormick et al. (2018).	Self exclusion, 6-12 months	74% with gambling problems n = 269	Gambling problems (vilket instrument?)	6 and 12 months

Note: PFN: personalized normative feedback; PF: personalized feedback.

Table 7. Summary of finding for PFN compared to no intervention.

Outcome	Follow-up: participants (no of studies) Reference	Result (95%CI)	Absolute effect	GRADE	Comments
Changes in gambling problem (SOGS and PGSI), University students	3 months: 447 (2 RCT) Martens et al. (2015); Neighbors et al. (2015)	SMD −0.21 (−0.42, 0.01)		Very low ⊕ΟΟΟ	–Two imprecision^a –One inconsistency^b
	6 months: 226 (1 RCT) Neighbors et al. (2015)	SMD −0.06 (−0.32, 0.20)		Very low ⊕ΟΟΟ	One small study without significant results
Gambling frequency
No of days  spent gambling	3 months: 583 (3 RCT) Cunningham et al. (2012); Martens et al. (2015); Neighbors et al. (2015)	MD 1.07 (−1.25, 3.38)		Very low ⊕ΟΟΟ	–Two inconsistencies^c –Two imprecisions^d
	6 months: 365 (2 RCT) Cunningham et al. (2012) Neighbors et al. (2015)	MD: 0.90 (−1.50, 3.30)		Very low ⊕ΟΟΟ	–Two imprecisions^d –One inconsistency^f
No of days spent  gambling (days spent gambling within 30 days, general population)	12 months: 139 (1 RCT) Cunningham et al. (2012)	Full PNF: no statistically significant difference Partial PNF: MD: −2.5 (−4.98, −0.02)		Very low ⊕ΟΟΟ Low ⊕⊕ΟΟ	One small study without significant results –Two imprecisions^a
Proportion of  gamblers ending their gambling session, Online gamblers/slots	Within one gambling session. Approximately 11,232 (1 cohort) Auer and Griffiths (2015a)	RD: 0.01 (0.00, 0.01) RR: 2.13 (1.63, 2.79)	10 more that stopped gambling compared to the control group.	Very low ⊕ΟΟΟ	–Two bias^e –One imprecision^g
Monetary losses
Losses	3 months: 366 (2 RCT) Cunningham et al. (2012); Neighbors et al. (2015)	MD: 14.36 (−74.44, 103.16)		Very low ⊕ΟΟΟ	–Two imprecisions^a –One inconsistency^c
	6 months: 366 (2 RCT) Cunningham et al. (2012); Neighbors et al. (2015)	MD: −17.36 (−36.76, 2.04)		Very low ⊕ΟΟΟ	–Two imprecisions^a –One inconsistency^c
	12 months: 139 (1 RCT) Cunningham et al. (2012)	No statistically significant difference		Very low ⊕ΟΟΟ	One small study without significant results
Theoretical loss Online gamblers	6 months: 5528 (1 RCT) Auer and Griffiths (2016)	PNF (χ^2= 32,08, df 5, p = 0.0001)		Very low ⊕ΟΟΟ	–Two inconsistencies^h –One bias^i
Deposit money,  Online gamblers	6 months: Low risk gamblers n = 623 At risk gamblers: n = 101 Problem gamblers n = 55 (1 NRS) Wood and Wohl (2015)	Statistically significant difference PNF for at risk gamblers No effect for other groups		At risk gamblers Very low ⊕ΟΟΟ Low risk gamblers/Problem gamblers very low ⊕ΟΟΟ	–Two bias^j –Two imprecision^k
					One small study without significant results
Bets ($),  University students	333 (1 RCT) Martens et al. (2015)	MD: −86.54 (−197.74, 24.66)		Very low ⊕ΟΟΟ	One small study without significant results

^aFew participants and wide CI. ^bDifferent scales and clinical heterogeneity. ^cThe results were inconsistent and evaluated/measured in different ways and the populations used did not have the same sample characteristics. ^dWide CI. ^eA cohort without control group, evaluation only once before and after. ^fThe results were inconsistent and evaluated/measured in different ways and the populations used did not have the same sample characteristics. ^gFew events. ^hMerging of results from five different intervention groups that have received little different actions. ⁱShortcomings in the result report. ^jRisk for confounding. ^kFew participants.

Table 8. Summary of finding: pop-up message.

Author (Participants, no of studies) Reference	Gambling mode/population	Results	GRADE	Comments
Outcome: time spent gambling
Broussard (2017) and Ginley (2016)  (116, 2 RCT) Broussard et al. (2017), Ginley et al. (2016)	Slots Students at university	MD: −28.13 (−82.77, 26.51)	Very low ⊕ΟΟΟ	−Two imprecision^a −One inconsistency^b −One indirectness^c
Floyd (2006)  (122, RCT) Floyd et al. (2006) & Stenbergh (2004 (101, RCT) Steenbergh et al. (2004)	Roulette	Heterogeneous results	Very low ⊕ΟΟΟ	−One inconsistency^d −Two imprecision^e −One indirectness^c
Jardin (2012)  (80, RCT) Jardin and Wulfert (2012)	Wheel of luck	Decreased, p < 0.05 in favor for intervention	Very low ⊕ΟΟΟ	−Two imprecision^f −One indirectness^c
Outcome: bets
Floyd (2006) (122, RCT) Floyd et al.  (2006) & Steenbergh (2004) (101, RCT) Steenbergh et al. (2004)	Roulette	Heterogeneous results	Very low ⊕ΟΟΟ	−One inconsistency^d −Two precision^e −One indirectness^c
Jardin (2012) (80, RCT) Jardin and Wulfert (2012)	Wheel of luck	Decreased, p < 0.05 in favor for intervention	Very low ⊕ΟΟΟ	−Two imprecision^f −One indirectness^c
Rockloff (2015) (130, RCT) Rockloff et al. (2015)	Slot	No difference regarding spins	Very low ⊕ΟΟΟ	One small study without significant results

Notes: CI: confidence intervals; MD: mean difference.

^aFew participants and wide CI.

^bDifference between the interventions.

^cLaboratory setting.

^dThe results were inconsistent, difference between the interventions).

^eNarrative analysis and few participants.

^fVery few participants and only one study.

Table 9. Summary of finding of pop up message: limitation in time or money as compared to control group/standard message.

Outcome	Participants (no of studies) Reference	Result MD/RD (95%CI)	Absolut effect per 1000	GRADE	Comments
Intervention
Length of gambling  session (minutes)	43 (1 RCT) Kim et al. (2014)	MD: −4.48 (−8.49, −0.47) SMD: −0.63 (−1.24, −0.01)		Very low ⊕ΟΟΟ	–Two imprecision^a –One indirectness^b
Intervention
Number of gamblers that  adhered to limits	56 (1 RCT) Wohl et al. (2014)	RD: 0.27 (0.04, 0.50)	270 (40 till 500 more)	Very low ⊕ΟΟΟ	–Two bias^c –Two imprecision^a –One indirectness^b

Notes: CI: confidence interval; MD: mean difference; RD: risk difference; SMD: standard mean difference.

^aVery few participants, wide confidence interval and only a single study.

^bPerformed in a laboratory setting.

^cRandomization unclear.

Table 10. Summary of findings of Limitation in time or money, as compared to no intervention.

Outcome	Participants (no of studies) Reference	Result MD/RD (95%CI)	GRADE	Comments
Online—cash in limit
Gambling frequency	441 (1 cohort) Nelson et al. (2008)	MD: −4.72 (−8.27, −1.17)	Very low ⊕ΟΟΟ	–Two bias^a –One imprecision^b –One indirectness^c
Bets/day	441 (1 cohort) Nelson et al. (2008)	MD: −1.51 (−2.66 till −0.36)	Very low ⊕ΟΟΟ	–Two bias^a –One imprecision^b –One indirectness^c
Bets (Euro)	441 (1 cohort) Nelson et al. (2008)	MD: 0.28 (−2.87, 2.31)	Very low ⊕ΟΟΟ	–Two bias^a –Two imprecision^d –One indirectness^c
% Losses	452 (1 cohort) Nelson et al. (2008)	MD: −0.01 (−0.07,0.05)	Very low ⊕ΟΟΟ	–Two bias^a –Two imprecision^c –One indirectness^c
Loss (theoretical loss)  Changes in deposit per months or week	500 (1 cohort) Auer and Griffiths (2013)	t value: −4.47 p < 0.0001	Very low ⊕ΟΟΟ	–Two bias^a –One imprecision^b
Online—limitation in time
Loss (theoretical loss)  Changes in deposit per day	500 (1 cohort) Auer and Griffiths (2013)	t value: −3.19 p < 0.0001	Very low ⊕ΟΟΟ	–Two bias^a –One imprecision^b
Hotels and other gambling venues
Time spent gambling	634 (1 NRS) Sharpe et al. (2005)	4.6 min difference, mean 3 min p < 0.001	Very low ⊕ΟΟΟ	–Two bias^e –One imprecision^f
Bets	634 (1 NRS) Sharpe et al. (2005)	11.7 more bets control, mean 211, p < 0.01	Very low ⊕ΟΟΟ	–Two bias^e –One imprecision^f
Losses (net)	634 (1 NRS) Sharpe et al. (2005)	5.2 Australian dollars less in mean loss compared to the control group 19.85, p < 0.001	Very low ⊕ΟΟΟ	–Two bias^e –One imprecision^f

Notes: CI: confidence interval; MD: mean difference; RD: risk difference. ^aA cohort without control group, evaluation of effect only once before and after. ^bLimited number of participation and only one study. ^cThe intervention took place 2005 and the ability/possibility to monitor gambling behavior has improved. ^dOne study with few participants and wide CI. ^eNo information about baseline data from both groups. ^fOnly one study with limited number of participants.

Table 11. Summary of findings for self-exclusion (short or long).

Outcome	Follow-up	Participants (no. of studies) Reference	Result MD/RD (95%CI)	GRADE	Comments
Self-exclusion, 6–12 months
Gambling problem (PGSI score)	6 months	269 (1 cohort) McCormick et al. (2018)	Mean value 1.3	Very low ⊕ΟΟΟ	–Two bias^a –One imprecision^b
	1 year	235 (1 cohort) McCormick et al. (2018)
Self-exclusion (1 week)
Money	2 months	60 (1 RCT) Caillon et al. (2019)	No statistically significant difference	Very low ⊕ΟΟΟ	One small study without significant results
Time spent gambling	2 months	60 (1 RCT) Caillon et al. (2019)	No statistically significant difference	Very low ⊕ΟΟΟ	One small study without significant results

Notes: CI: confidence intervals.

^aDrop-out.

^bFew participants.

Figure 3. (a) RCT and NRS with low or moderate risk for bias. (b) Cohort—low or moderate risk of bias.

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