The present study, carried out when a new nationwide self-exclusion service had already been in use for almost 3.5 years, demonstrated that nine percent of past-year gamblers had ever used this self-exclusion service. Although head-to-head comparisons with other studies are difficult, a comparison with three previous online surveys from the present setting, addressing the same self-exclusion service, indicates that its popularity may have increased. On the other hand, breaching of one’s self-exclusion appears to be common, and may have increased to some extent since a comparable survey one year earlier. Thus, the present study displays the high level of use of this type of harm reduction tool in gamblers, but also presents challenges that need to be addressed in future policy work in this area.
In the study carried out in March2021, primarily addressing potential COVID-19-related changes in the gambling market, five percent of gamblers had ever self-excluded through the Swedish self-exclusion service [10]. In the study from 2020, seven percent of participants with 10 occasions or more of past-year online gambling had ever self-excluded [7]. In the present study, around nine percent endorsed a history of self-exclusion. Given the growing experience of self-exclusion since the introduction of this service in 2019, it may seem unsurprising that the proportion having used the service was higher in the present study. Although the figures cannot be directly compared head to head, due to some differences in the samples assessed, it can be hypothesized that the present self-exclusion service is increasingly known by the general public over time. Likewise, however, the proportion of self-exclusion breachers was somewhat higher in the present study; 49 percent compared to 38 percent in the 2020 survey [7].
The breaching of self-exclusion is not a surprising finding, and constitutes a well-known limitation to self-exclusion services overall [6]. The specific interest in the present findings, however, is the fact that the Swedish self-exclusion service has been designed specifically to provide exclusion from a very broad range of gambling operators, including all companies with a license to operate in the Swedish jurisdiction, and involving gambling types as diverse as land-based casino gambling, online casino or card gambling, or sports betting conducted online or in bookmaker venues. The present study again demonstrates the particular challenges of online gambling, over and above the well-known risks of gambling overall. Online casino and online live-based sports betting constitute a more accessible and more rapid gambling modality than traditional venue-based land-based gambling [13]. In addition to that, as demonstrated by the present and previous study gambling [7], online gambling appears to be particularly difficult to self-exclude from, due to the availability of online-based operators outside the jurisdiction of Spelpaus. The clinical significance of this is obvious and has been confirmed in recent reports from a treatment unit [9]. Thus, while patients with a gambling disorder appear to self-exclude to a relatively large extent, it is obvious from such clinical data that their need for treatment remains, based on the risk of breaching, pointing to the further need for accessible treatment despite the existence of self-exclusion services. In addition, online casino was the only specific gambling types which was associated with the reporting of having self-excluded. Thus, although a number of gambling types with addictive potential were included in the study, online casino appears to have a specific position as gambling behavior surrounding the decision to self-exclude. Interestingly, for example, sports and horse race betting were not more commonly reported by responders reporting self-exclusion, than among others. Also, while other gambling types were more common in self-excluders, they were no longer associated with self-exclusion when controlling for online casino and variables describing gambling problems. Again, this points to the importance to continue to follow the addictive properties of online casino, also given its predominance in treatment-seeking clients in this setting [9].
Also, mental health problems were more common in self-excluders than in other respondents. This is in line with previous data [7], but in both studies, mental health problems were no longer associated with self-exclusion after controlling for gambling-related and other variables. In this study, mental health problems were measured with a single question about therapy history, as opposed to a previously used six-item scale [7]. Nonetheless, it appears that mental health problems may have a weaker link to self-exclusion than the actual gambling-related behaviors themselves.
The gambling types used during self-exclusion are comparable to those reported in 2020, although the absolute number of participants reporting breaching at that time was low [7], and therefore exact proportions of gambling types should be interpreted with caution. However, in the present study, 82 percent of those reporting breaching of self-exclusion reported online casino, compared to 52 percent in the previous study. Sports betting was also somewhat more common, 47 percent in the present study compared to 16 percent in the previous study. Likewise, restaurant casinos were reported by 24 percent in the present study, and although this absolute number is low, it was lower in the previous study [7]. It may be difficult to conclude whether these proportions represent any actual changes in the gambling market accessed for self-excluded individuals who relapse into gambling, and here, further studies in larger datasets may be needed. However, an overall concentration of problem gambling to online casino primarily, and also to sports betting, has been seen among treatment-seeking patients [9], and the high proportions of online casino and sports betting in self-exclusion breaching could be seen as consistent with this.
The factors associated with having breached self-exclusion were also reported as groupwise comparisons, but due to the relatively small sample size in that sub-study, a more extensive statistical analysis of these factors could not be carried out. However, the groups of self-excluders reported breaching and those who did not, differed with respect to gambling-related variables; gambling problems were even more common in those reporting breaching than in other self-excluders, and several gambling types were more commonly reported by those reporting breaching, and even more gambling types had a marginally significant difference between the groups. Overall, this points to a more intense gambling patterns in the respondents who reported to have gambled during their self-exclusion than among those who remained gambling-abstinent during self-exclusion. It further emphasizes the need to study the risk factors of breaching one’s self-exclusion and how policy makers can improve this harm reduction tool in order to increase its efficacy in individuals with intense gambling practices.
Voluntary self-exclusion through the present nationwide, multi-operator model appears to be a popular harm reduction tool in Sweden; even though the sample addressed in the present study was not necessarily gambling as frequently as in the study from 2020 (past-year gambling in the present study compared to past-year gambling on 10 or more occasions in the 2020 study), the proportion reporting self-exclusion was not larger. It remains to be understood what reasons are behind self-exclusion in individuals who do not fulfill the criteria of gambling problems. It also cannot be excluded that self-exclusion may attract family members or partners of individuals struggling with a GD, in order to provide motivational or moral support to the patient, or potentially in order to prevent gambling on other family members’ identity. While this goes beyond the scope of the present study, it merits further research to examine why people without measurable gambling problems may choose to self-exclude. In addition, the present self-exclusion system prohibits gambling operators to address a self-excluded individual with direct postal or electronic advertising. Potentially, this may also add to the rationale behind self-excluding in the absence of gambling problems.
The present study has some limitations, primarily due to its design as a web survey, where the format is required to be kept brief, and where more thorough diagnostic examination cannot take place. The subjective, self-report-based information about self-exclusion may also be limited by recall bias. Nonetheless, the items addressing self-exclusion have been worded in the same way as in previous studies [7,8,10], making comparisons possible.
In conclusion, self-exclusion remains a well-established and common harm reduction tool applied by individuals with gambling problems, but breaching of one’s self-exclusion is common, possibly somewhat more common than in previous comparable research from the same setting [7]. Breaching of self-exclusion may be seen as a natural consequence of a GD, and something common among individuals with gambling problems and with intense gambling practices. This may also be particularly challenging in a strongly online-dominated gambling market. In Sweden, online gambling represents the vast majority of gambling patterns for which patients seek treatment [9]. This may lead to a larger risk of self-exclusion breaching than in a more traditional, land-based gambling market. Aiming towards lower risk of self-exclusion breaching, further policy work may be needed in order to improve regulations around self-exclusion, such that overseas gambling operators can more easily be kept outside the market.