Social Science & Medicine 326 (2023) 115885

Contents lists available at ScienceDirect

SOCIAL
NCE
Social Science & Medicine

ELSEVIER journal homepage: www.elsevier.com/locate/socscimed

The role of mental health in online gambling decisions: A discrete e

choice experiment
Lachlan Cameron , Jemimah Ride
Health Economics Unit, School of Population and Global Health, The University of Melbourne, 207 Bouverie St, Carlton, Victoria, 3053, Australia

ARTICLE INFO ABSTRACT

Handling Editor: R Smith People with mental health problems are more likely to experience problems due to gambling, an intersection of
— two sources of social disadvantage. However, the mechanisms by which this occurs remain unclear. Analysing if
Keywords: choices while gambling differ for people with mental health problems, and whether these differences involve
Problems due to gambling characteristics linked with gambling harms, can improve this understanding. Evidence on this is limited because
Online gambling most studies rely on survey questions or aggregate data which are either self-reported, unlikely to allow for
Horse racing identification of separate features of gambling options, or do not observe the full set of options people are
Marketing strategies
Mental health problems choosing between.
een. | Discrete Choice
i Experiments
. can circumvent these issues by observing the gambling envi-
Discrete choice experiment ronment and individual’s gambling choices.
This study uses a Discrete Choice Experiment to analyse people’s choices while gambling, and if these differ for
people with mental health problems. Participants were offered a series of 6 choice sets representing online
gambling on horse racing; each presented two hypothetical horse races, both with eight horses, differing in the
information they provided. Participants chose which race (if any) and horse they would bet on. The choices were
modelled using mixed logit models.
People with mental health problems had (i) a lower preference for betting on races with information about
horses® recent form and (i) preferred betting on horses with higher odds. (i) Could indicate that they put less
thought into their bet, a sign of gambling as an escape. (ii) Could indicate that they are more risk seeking. These
are two gambling characteristics linked with problems due to gambling and are plausible mechanisms by which
people with mental health problems may be more likely to develop problems due to gambling.

1. Introduction of evidence on the impact of specific, modifiable elements of gambling

Problems due to gambling occur when gambling behaviour causes
significant harm for the individual, their friends and family, or the
community (Ferris and Wynne, 2001). Worldwide estimates of the
prevalence of people experiencing problems due to gambling range
between 0.12 and 5.8% of the legal-aged population (Calado and Grif-
fiths, 2016). While gambling can be a safe recreational activity for some,
possible consequences include financial hardship, relationship break-
down, poorer health, decreased work productivity, and crime (Browne
etal, 2017).
‘Responsible gambling’, which puts the onus on the individual to
avoid problems due to gambling, is criticized for failing to address the
environment created by gambling products within which the individual
makes their gambling choices (Livingstone and Rintoul, 2020). Progress
on harm reduction strategies in gambling has been hampered by a lack
products on gambling behaviour.
1.1. Different types of gambling decisions
Gambling behaviour can be examined as a series of related decisions.
These decisions include whether to bet, the betting platform (online or
in-person), the gambling activity (e.g. horse racing, electronic gaming
‘machines, casino games), the event (e.g. sports match, horse race), the
type of bet (e.g. win or place, win or first goal scorer, number or red/
black), which item(s) to bet on (e.g. horse, team, person), and how much
¢ pet Existing literature has explored the prevalence of gambling
pricivation (Rockloff et al., 2020), rates of online versus in-person
gt tine (MoraSalguciro et al., 2021, common gambling activities
(Columb and O'Gara, 2018), common types of bets and amount bet
(G aingbury and Russell, 2015), and how the prevalence of these relate to

* Corresponding author.
E-mail address: Icameron] @student unimelb.edu.au (L. Cameron).
https://doi.org/10.1016/j.socscimed.2023.115885
Received 6 November 2022; Received in revised form 28 March 2023; Accepted 31 March 2023
Available online 13 April 2023
0277-9536/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
L. Cameron and J. Ride
the likelihood of experiencing or developing problems due to gambling
(e.g. see Effertz et al. (2018), Hing et al. (2017a), and Rockloff et al.
(2020)).
There has been limited exploration of how people choose the event
and item that they bet on and how this may relate to experiencing
problems due to gambling. One reason for this is that much of the
existing quantitative literature in gambling uses real-world data, such as
from population surveys or databases of gambling companies. Popula-
tion surveys are unlikely to have information at the event (e.g. race) or
item (e.g. horse) level and hence can not explore these choices. Data
from gambling companies may have this level of information (as in
Gainsbury and Russell (2015)), but are unlikely to include the infor-
mation about each event and item that was provided to the gamblers (e.
g. odds, expert tips, special offers), the full set of options people were
choosing between, or characteristics of the people making each bet (e.g.
experience of problems due to gambling). These data are needed to
analyse the separate impact of different features of the events and items
on people’s choices. Analysing what influences people's choices of event
and item can provide insight into the reason people bet (e.g. gambling as
an escape) and gambling characteristics (e.g. risk preferences). Under-
standing these aspects of gambling choices, and how they relate to
problems due to gambling, can provide information on a specific set of
factors that could be modified to reduce gambling harm.
Two gambling behaviours of particular interest are gambling as an
escape and risk preferences, because they are hypothesised to lead to
problems due to gambling. Using gambling as an escape - when people
gamble to take their mind off other things - is likely to result in less
thought being put into the bet and betting more regularly (Blaszczynski
and Nower, 2002). Because of the house edge (Levitt, 2004), this in-
creases the likelihood and size of gambling losses. People who are more
risk seeking are likely to place larger bets or bet on events with a lower
probability of winning (Taoka and Kusumi, 2021). This results in a
higher chance of losing money and losing larger amounts. These
behavioural characteristics have been linked with experiencing prob-
lems due to gambling (e.g. see Flack and Morris (2015), Wichler and.
Peters (2015), and Wood and Griffiths (2007)). Qualitative (Wood and
Griffiths, 2007) and quantitative (Flack and Morris, 2015; Flack and
Stevens, 2019; Schellenberg et al., 2016) studies have identified
gambling as an escape as a key factor associated with experiencing
problems due to gambling, and Wichler and Peters (2015) associated
experiencing problems due to gambling with being more risk seeking.
However, the measures of gambling as an escape and risk preferences
used in these studies were elicited through survey questions rather than
real-world gambling decisions, which reduces their real-world applica-
bility in terms of informing policy that modifies the gambling environ-
ment to reduce rates of people experiencing problems due to gambling.
Marketing of gambling products is a focus for harm reduction
(Newall et al, 2019a). There are a range of marketing strategies used in
gambling, including digital advertising (commonly shown on television
or social media), ‘experts’ providing suggestions for bets, and in-
ducements. Inducements are promotions offering incentives to gamble
such as better odds or refunds (Hing et al., 2017b). Existing studies using
self-reported measures of gambling behaviour have found that market-
ing strategies can increase the frequency at which people bet and the
amount bet (Browne et al., 2019; Hing et al., 2019). These studies rely
on self-reported survey data rather than observation of gambling
choices. One experimental study analysing gambling choices found that
inducements, specifically cash rebates, increase the likelihood of placing
bets with a lower expected payoff (Rockloff et al., 2019). To date, few
studies have explored the influence of marketing strategies on people's
choice of which event and item to bet on. Analysing how marketing
strategies influence people’s choice of event and item provides a broader
understanding of how marketing strategies influence gambling decisions
and their possible impact on gambling harms, and can help to inform
policy regulating these types of marketing.
Social Science & Medicine 326 (2023) 115885
1.2. Mental health problems and gambling behaviour
People with mental health problems such as anxiety and depression
are more likely to experience problems due to gambling (Rockloff et al.,
2020). Mental health problems are common causes of social disadvan-
tage (Stanton et al., 2020) that in combination with problems due to
gambling could compound disadvantage and harms. The causal effects
and the underlying mechanisms between these two remain unclear.
There may be causal effects in both directions (Dussault et al., 2011).
This study focuses on whether mental health problems contribute to
developing problems due to gambling. Mental health problems can
affect people’s cognition and behaviour (Perini et al., 2019) and may
therefore influence the way people gamble, possibly in ways that in-
fluence their likelihood of developing problems due to gambling. By
analysing how the choice of event and item differ for people with mental
health problems, we can explore whether people with mental health
problems have different characteristics such as (i) propensity to gamble
as an escape, (ii) risk preferences, and (iii) responsiveness to marketing
strategies. Given the possible association of these characteristics with
experiencing problems due to gambling discussed above, this can pro-
vide insight into plausible pathways by which people with mental health
problems may be more likely to develop problems due to gambling.
This directional effect is important to understand because gambling
may disproportionately harm people with mental health problems,
exacerbating existing disadvantage and making it more difficult for
these people to improve their mental health. Improving understanding
will provide evidence on the need for policy that aims to reduce the risk
of experiencing problems due to gambling for people with mental health
problems, and the types of interventions that could do this effectively.
1.3. Aim and approach
In this study we aim to analyse what influences people’s choice of
which event and item to bet on when gambling, and whether this differs
for people with mental health problems. We use this information to
discuss how propensity to gamble as an escape, risk preferences, and
responsiveness to marketing strategies differ for people with mental
health problems, and if these differences suggest that people with
‘mental health problems may be more likely to develop problems due to
gambling.
We do this by implementing a Discrete Choice Experiment (DCE). A
stated-choice experiment such as a DCE can circumvent the shortcom-
ings of real-world data outlined above. It allows us to capture infor-
‘mation on the features of each event and item chosen (and not chosen),
and characteristics of the individuals making each bet. This enables the
exploration of what influences people’s decision of which event and
item to bet on, and if gambling characteristics differ for people with
‘mental health problems. DCEs have been used in gambling before (e.g.
see Rockloffet al. (2017), Song et al. (2021), and Teichert et al. (2021)).
However, these explore preferred gambling environment (e.g. preferred
electronic gaming machine venue, gambling website, casino), and did
not aim to elicit preferences while gambling (including preferences for
event and item). Using a DCE to elicit preferences while gambling is
complex because in a real-world setting there are multiple interrelated
stages of choice and the features of gambling options may not be obvious
to participants. This raises difficulties with (i) defining the alternatives,
attributes, and levels, (ii) the presentation of the attributes and levels to
participants, and (iii) the statistical analysis of choices. In this paper we
detail how we deal with these issues.
The DCE in this study was set in the context of online gambling on
horse racing in Australia. Australia has the highest per capita gambling
losses in the world (Roth, 2020). Horse racing is associated with high
rates of gambling participation and people experiencing problems due to
gambling (Rockloff et al., 2020). Online gambling is associated with a
greater risk of experiencing problems due to gambling than in-venue
gambling (Effertz et al, 2018), has a close association with horse
L. Cameron and J. Ride
racing, and is increasing in prevalence (in Australia, the percentage of
horse racing gamblers who gamble online has increased from 6.8% in
2008 to 34.7% in 2020) (Rockloff et al., 2020). Horse racing is also
appropriate for analysing the choice of event and item because features
of these options differ, compared with many casino games or electronic
gaming machines where each event and item offer the same information.
1.4. Contributions
This paper has three main contributions to the literature. Firstly, we
improve knowledge about how infor-mation provided to people when
gambling, including marketing strategies, influences gambling de-
cisions. We do this by analysing their effect on choice of event and item,
which are rarely explored gambling decisions. We do this in the context
of online gambling on horse racing, analysing how information about
races and horses influences people’s choice of race and horse. Secondly,
we provide insight into how people’s gambling characteristics such as
propensity to gamble as an escape, risk preferences, and responsiveness
to marketing strategies differ with their mental health. We capture
gambling to escape through preference for races with form (representing
how much thought is put into the choice) and gambling frequency. We
capture risk preferences through the odds of horses in each race. Com-
mon marketing strategies (expert tips and inducements) were included
in the design. This can provide evidence on whether mental health
problems may contribute to a higher likelihood of developing problems
due to gambling. Thirdly, we illustrate the feasibility of using a DCE to
explore decisions while gambling.
1.5. Findings
We find evidence that people are more likely to bet on races with
marketing strategies (such as an expert tip or an inducement), and prefer
betting on horses with lower odds. Exploration of preference heteroge-
neity shows that people with mental health problems have a lower
preference for races with form and a greater preference for horses with
higher odds, compared to people without mental health problems,
robust to controlling for problems due to gambling. A possible expla-
nation for a lower preference for races with form is putting less thought
into the bet, consistent with gambling as an escape. A preference for
horses with higher odds indicates preferring riskier bets and being more
risk seeking. Therefore, these results suggest that people with mental
health problems may be more likely to gamble as an escape, and are
more risk seeking. These are two characteristics linked with experi-
encing problems due to gambling (Flack and Morris, 2015; Wiehler and
Peters, 2015) and hence suggest two plausible mechanisms by which
people with mental health problems may be more likely to develop
problems due to gambling.
The paper proceeds as follows. Section 2 discusses the methods used
and the survey and experimental design, Section 3 presents the results,
and Section 4 discusses the implications of the results.
2. Method
This study uses a Discrete Choice Experiment (DCE) to elicit pref-
erences for features of races and horses while gambling online on horse
racing. DCEs are an increasingly common method to elicit preferences
for a good or service (Sockhai et al., 2019). DCEs are consistent with
Lancaster’s theory of demand, which states that consumers have pref-
erences for and derive utility from underlying attributes of goods rather
than the goods themselves (Lancaster, 1966), and draws on random
utility theory (Kjaer, 2005).
DCEs show participants a series of choice sets, each offering two or
more alternatives of a good or service. The alternatives are described by
a set of attributes, where the levels of the attributes may differ for each
alternative and each choice set. The attribute levels describing each
alternative follow an experimental design. The purpose of the
Social Science & Medicine 326 (2023) 115885
experimental design is to vary the levels in each alternative and choice
set in a way that ensures participant responses can efficiently identify
preferences for each of the attribute levels. This results in participants
observing alternatives with a wide variety of attribute level combina-
tions. Participants are asked to choose which alternative they would
prefer, and are assumed to choose the alternative with the mixture of
attribute levels that they expect to give them the highest utility. From
these choices, econometric models can estimate participant's prefer-
ences for the attributes and levels.
2.1. Sample and data collection
Participants of the study were recruited through an online panel from
December 2021 to January 2022. The sample had quotas for age,
gender, and state matched approximately to the Australian population.
Inclusion criteria were people who were 18 years of age or older and
lived in Australia. People were screened out of the survey if they stated
that they both had not and would not gamble online. There were no
other inclusions or exclusion criteria.
Our main analysis included people who had not gambled online
before, if they indicated that they would gamble online. This was to
include preferences of all people who may be subject to an online
gambling environment in the future, and who for which mental health
may influence their gambling behaviour and risk of developing prob-
lems due to gambling. Given the potential complexity of the survey, a
series of sensitivity analyses were conducted based on people’s famil-
iarity with the environment presented in the survey. For these, the
sample respectively excluded people who had not gambled on horse
racing before, people who had not gambled online on horse racing
before, and people who stated they found the survey difficult.
The survey was conducted online so was only completed by people
who have internet access. This limitation to potential online gamblers
naturally excluded those without internet access, whose preferences
would not be relevant to policy in the online gambling space.
Two pilots of approximately 50 participants each were conducted
before the final survey was released. The survey was modified after the
first pilot, and hence these participants were removed from the final
sample. We reduced the number of levels of the odds attribute to
simplify the statistical design, and edited the questions eliciting personal
characteristics about participants. The survey was not modified after the
second pilot, and so these participants were included in the final sample.
This study received ethics approval from the Human Research Ethics
Committee of The University of Melbourne (reference number: 20350).
2.2, Design
2.2.1. Survey design
This DCE used an online survey made up of four parts: (i) screening
questions, (ii) background information and instructions for how to
complete the survey, (iii) a series of six choice sets, and (iv) questions to
elicit personal characteristics about participants (see supplementary
‘material for the full survey).
Participants of the DCE were asked to imagine they have an online
gambling account which they use to bet on horse racing, and that they
had just deposited AUD$100 into this account. In each of the six choice
sets, they were shown two hypothetical horse races, each with eight
horses. They were asked to choose which race they would bet on, or if
they would not bet on either. If they chose to bet on one of the races they
were then asked which horse within that race they would bet AUD$10
on to win.
The scenario was restricted to betting AUD$10 and on a horse to win
to limit the scenario to two choices.
This was to reduce cognitive burden for participants and simplify the
‘modelling approach. Although the type of bet and amount bet are open
to choice in a real-world setting, they are often predetermined by
gamblers (unlike choice of race and horse which rely on being shown
L. Cameron and J. Ride
information about the betting options). AUD$10 has been found to be
the median amount bet on horse racing in Australia. Betting on a horse
to win (rather than alternatives such as a horse to place, or more
complicated bets like a trifecta or a multiplier) is the most common type
of bet when gambling on horse racing (Gainsbury and Russell, 2015).
2.2.2. Key measures
Measures of mental health were gathered through three questions:
the 7-item Generalized Anxiety Dis- order Questionnaire (GAD7) (Spit-
zer et al., 2006), (if) the 9-item Patient Health Questionnaire (PHQ9) for
depression (Kroenke et al., 2001), and (iii) a single question asking if the
participant currently has depression and/or anxiety disorder that has
been diagnosed or treated by a health professional. We created a binary
variable from the three mental health measures captured in the survey.
This indicated if the individual had, or was showing symptoms of,
anxiety or depression (MHP): equal to 1 if they scored 10 or more on the
GAD7 (moderate or higher symptoms of anxiety), 10 or more on the
PHQO (moderate or higher symptoms of depression), and/or a
self-reported current diagnosis of or treatment for depression and/or
anxiety, and 0 otherwise. Our main analysis used this combined measure
because we were interested in both people who were showing moderate
or higher symptoms, even if they have not been formally diagnosed with
depression or anxiety, and people with existing depression and/or
anxiety, even if they were not currently showing moderate or higher
symptoms. This is because these are all people likely to be at a social
disadvantage due to their mental health. Depression and anxiety were
modelled as a combined variable because they are highly correlated
(Lamers et al., 2011) (see Table Al in the online appendix for the cor-
relation between the mental health measures in our sample). Sensitivity
analyses including the individual measures separately, and differing the
cut-off points in how mental health problems were defined, were
conducted.
We also asked questions about gambling experience. These included
the usual frequency of their gambling, if they had gambled online on
horse racing before, and the 9-item Problem Gambling Severity Index
(PGSI) (Ferris and Wynne, 2001). Current experience of problems due to
gambling (PG) was captured with a binary variable equal to 1 if they
scored 3 or greater on the PGSI (moderate or higher risk of problems due
to gambling) and 0 otherwise.
2.2.3. Auributes and levels
The attributes and levels used in the experimental design of the
survey were features of each race (rather than each horse). Each race
was described by five attributes: (i) the set of race odds, (if) time until
the race starts, (iii) whether information about the horse’s past form
(recent race results) was provided, (iv) whether an expert tip was pro-
vided, and (v) whether an inducement was offered. The full list of levels
is presented in Table 1.
The attributes and levels were primarily chosen based on what is
Table 1
List of attributes and levels.
Attribute Level
Race Odds 0. No favourite, spread field (3 horses with odds less than §10)
1. No favourite, spread field (3 horses with odds less than $10)
2. With favourite, spread field
3. With favourite, even field
Time 0.10 min until the race starts
1.3 min until the race starts
Form 0. Form not provided
1. Form provided
Tip 0. No tip
1. Tip on favourite (i.e. favourite predicted to win)
2. Tip on 3rd favourite (i.e. 3rd favourite predicted to win)
Inducement 0. No inducement
1. Money back special
2. Increased odds
Social Science & Medicine 326 (2023) 115885
commonly seen in real-world online gambling on horse racing scenarios.
Discussions with consumers and an expert advisory panel confirmed
these to be appropriate. They were also chosen based on their ability to
answer the relevant research questions. The form and time until the race
starts attributes, and the option to opt out, were designed to capture
propensity to gamble as an escape. Lower preference for races with form
could signal that the participant puts less thought into their bet, and
(i) hence is more likely to be gambling as an escape. Frequency of gambling
in the DCE was indicated by preference for the race in 3 min instead of
10 min (i.e. not waiting as long before placing the next bet) and being
less likely to opt out (i.e. making more bets across the choice sets in the
DCE). Greater betting frequency is also a sign of gambling as an escape.
Expert tips and inducements were included to explore the influence
of marketing strategies. Greater preference for races with expert tips or
inducements signal a greater responsiveness to marketing strategies.
Inducements are a specific type of marketing strategy that modify the
gambling environment. The two levels of inducements were a money
back special and increased odds - two common inducements in Australia
(Hing et al., 2017b). When a money back special is offered, a bet on a
horse to win is returned in bonus bets if the horse comes second or third.
When increased odds is offered, the odds of each horse is framed as if it is
higher than it normally would be (note that in the survey this induce-
‘ment did not actually increase the odds - it was only framed as if it did).
The levels of the set of race odds were taken from real horse races in
Australia. A favourite refers to the horse with the lowest odds - the horse
that is the most likely to win but has the lowest potential payoff.
Differing the levels of race odds was to reduce repetition and, by offering
different types of race odds, improve the robustness of results (e.g.
preferences for races with given attributes not limited to races with
certain odds). The odds of the specific horses were used to explore risk
preferences. The odds of horses can be used to explore risk preferences
because they are intrinsically linked with both the likelihood of winning
and the expected payoff. For example, a bet on a horse with higher odds
has a higher potential payoff but a lower probability of winning, indi-
cating a riskier bet and hence a greater level of risk seeking behaviour.
We excluded attributes such as jockey name, horse name, trainer,
and uniform colour because it would be difficult to ascertain any
meaning to preferences for these attributes in hypothetical scenarios.
Some online gambling companies offer information such as horse’s
weight, fluctuation in odds, and rating. We chose to not include these as
attributes to reduce cognitive burden and because behaviour inferred
from preferences for them could be largely captured already by the
included attributes (i.e. these would mainly capture amount of thought
put into the bet, which is already captured by the form attribute).
Real-world gambling is complex and attributes and levels of the bet
may not be obvious to gamblers. Therefore, to minimise hypothetical
bias, the attributes and levels in this study were not all presented
explicitly to participants. For example, the race odds were presented as a
set of odds rather than specifying if it had a favourite or the spread of the
field. It was not explicitly stated whether the expert was tipping the
favourite or the third favourite to win. The money back special and
increased odds were not described as inducements. The layout of the
choice sets was based on real-world online gambling companies. An
example choice set is provided in Fig. 1.
See supplementary material for further detail on the design and
rationale of each of the attributes and levels, and how they were pre-
sented and described to participants in the survey.
2.2.4. Experimental design
The experimental design of the choice sets was generated using
NGENE 1.2.1 (ChoiceMetrics, 2018). We used a Bayesian d-efficient
design with 24 rows separated into four blocks (six choice sets in each
block). Each participant was randomised to one of the four blocks. The
attributes were effects-coded, and the design allowed for all two-way
attribute interactions. The design was restricted such that the level of
the time attribute for Race A was always 3 min and Race B was always 10
L. Cameron and J. Ride Social Science & Medicine 326 (2023) 115885

uation: You haveJust log ed on to your onlin mbiing ac ount and deposited$1
unt balance on a horse to win a race. wo races are as shown below. Click Dere to re
hereto eturn to the ‘Background Information’ screen for a reminder on the information about this su

Please hether you would bet $10 from your account balance on one of these races or f you would not bet on efther. »

Iwould
bet on race A 1 would bet on race B. 1 would not bet on sither race.

== B
p=—) =a

EXPERT TIPS -Race A EXPERT TIPS race &

Fig. 1. Example of a choice set presented to participants. Race A has attribute levels: with favourite and even field, 3 min until the race starts, form not provided, tip
on favourite, increased odds. Race B has attribute levels: no favourite and spread field, 10 min until the race starts, form provided, tip on third favourite, money back
special. Note that some of the races did not have an inducement and/or did not have an expert tip. Races without an inducement had a blank space above the race
where the inducements are shown here. Races with an expert tip had a blank space below the race where the expert tips are shown here. See the survey in the
supplementary material for examples.

min because it is unrealistic for two horse races in Australia to run at the The correlated random coefficients accounts for correlation due to scale
same time. The order of the choice sets were randomised for each heterogeneity (Hess and Train, 2017). A mixed logit model also allows
participant, and the order of the horses within each race were rando- for the panel structure in the data (due to each participant answering six
mised for each participant and race. The order of the alternatives was choice sets), and exploration of observed preference heterogeneity
not randomised because it is unrealistic for the race displayed on the through interaction terms.
right to have less time until it starts than the race displayed on the left. Following standard specifications (Lancsar et al., 2017), we assumed
that individual i, when choosing race r in choice set c, derived utility
2.3. Statistical analysis according to
Vier=Vier*ticr @
Participants made two choices in each choice set: (i) on which race
they would bet (if any) and (ii) on which horse they would bet (condi- where Vi, is the systematic part of the utility and &;.- represents unob-
tional on (i)). These two choices were modelled separately. Choice of servable factors that are assumed to be independent and identically
race provides information on what affects whether someone bets, and distributed extreme values. Participants were assumed to be random
choice of horse on the riskiness of that bet. utility maximisers and hence choose the race which had the mix of
attribute levels that they expect to give them the highest utility.
2.3.1. Choice of race The systematic component of the utility was modelled according to
Since the attributes and levels in the experimental design were fea- the equation
tures of the race, participants’ choice of race could be analysed using
standard choice models commonly used in analysis of DCESs, treating Viy =ASC,a + Xiosp + Zieid @
cach race as the alternative. ASC,; refers to an alternative specific constant denoting whether the
‘We estimated choices using mixed logit models (Revelt and Train, race is an active (Race A or Race B) or opt-out (no bet) option, Xi;- de-
1998) with correlated random coefficients. A mixed logit model is a scribes the attribute levels of race r (including two-way attribute
flexible model which allows for unobserved preference heterogeneity.
L. Cameron and J. Ride Social Science & Medicine 326 (2023) 115885

interactions), Zi.r are personal characteristics describing participant i the survey in a significantly shorter time than average (e.g. see (Yang
(interacted with the ASC and attribute levels of race r), and a, 5, 5 are and Hobbs, 2020)), this may omit valid preferences (Lancsar and Lou-
parameters to be estimated. viere, 2006). See Tables A2 and A3 in the online appendix for descriptive
Model 1 in the analysis was without preference heterogeneity (i.e. statistics of completion time and straight-line responses respectively.
assuming § = 0 in (2)). Model 2 added mental health variables. We The median completion time in this survey was 10 min 37 s, and the
interacted a mental health variable with all attribute levels and the ASC. minimum completion time of 6 min 1 s was considered a feasible time to
Mental health interactions were included to explore how gambling de- complete the survey genuinely. 28 participants always chose Race A, 13
cisions differ for people with mental health problems. Mental health was always chose Race B, and 60 always opted out. However, given Race A
interacted with all attribute levels because preferences for each attribute and Race B always differed the same way in the time attribute, there are
level elicits information about gambling characteristics and may be logical explanations for why someone would always prefer a given race
related to likelihood of experiencing or developing problems due to (i.e. strong preferences for a sooner or later time until the race starts).
gambling. Model 3 included both mental health problems and problems Participants who always opted out may have bet on some races if they
due to gambling in Z. This was both to account for problems due to were shown different choice sets. While we considered all responses to
gambling, which is correlated with mental health, and to explore simi- be valid, to test the impact on our findings we conducted sensitivity
larities between gambling characteristics for people with mental health analyses excluding those with straight-line responses and with a
problems and people experiencing problems due to gambling. completion time in the bottom 10% of the sample.
A series of sensitivity analyses were also conducted: the three mea- The full list of descriptive statistics for the sample are presented in
sures of mental health included indi-vidually in separate models, Table 2. Most of the sample (85.71%) had participated in gambling in
different cut-offs of the mental health measures, sub-samples based on the past 12 months, had gambled on horse racing before (84.20%), and
gambling experience and potentially inattentive responses, and had gambled online on horse racing before (60.58%). More than a
including MHP x PG interactions in Z in addition to Model 3. quarter of the sample (26.79%) were experiencing problems due to
gambling, which is higher than population samples (e.g. 3.1% in
2.3.2. Choice of horse Rockloff et al. (2020)), reflecting that the inclusion criteria was
The choice of horse was modelled similarly to modelling choice of weighted towards gamblers and consistent with evidence that online
race (mixed logit models with correlated random coefficients), except surveys have higher rates than telephone or in-person surveys (Russell
here choices were described by attributes of the horse chosen (rather etal., 2022).
than the race chosen). In line with this, while the choice of race models Just over a third of the sample (34.62%) were defined as having a
had fixed effects at the individual and choice set level (as is customary in
discrete choice models), the choice of horse models had fixed effects at
the individual and race level. To our knowledge, this approach to Table 2
modelling the choice of horse is novel and a main strength of this study. Descriptive statistics for all participants in the final sample. Values represent
‘This approach allows for modelling multiple choices, which is important percentage of the respective columns sample size. For all statistics except survey
when analysing gambling choices. difficulty: *p < 0.05, **p < 0.01, ***p < 0.001 based on two-tailed t-test. For
We assumed that participant i, when choosing horse h in race r and survey difficulty: *p < 0.05, **p < 0.01, ***p < 0.001 based on Wilcoxon rank-
choice set ¢, derived utility according to
sum test. Any MHP - Any Mental Health Problem. HR - anyone who has gambled
on horse racing before. OHR - anyone who has gambled online on horse racing
Vierh=Vierh**icrh 3) before. PG - people with moderate or higher risk of experiencing problems due to
gambling (PGSI > 2).
where the systematic part of the utility (Viers) now includes information Variable Al Any HR OHR »G
about the individual horses. The systematic component of the utility was MHP
modelled according to the equation N= N=252 N=613 N=-44 N=195
728
Vien = In (0dds),@ + Xien + Ziewd “@
Mental Health
In(0dds);cry denotes the odds of horse h (scaled by the natural log func- Depressive symptoms 23.49 2251 22.00 4256+
tion). Xien,still denotes the attribute levels of the race, but here these are (PHQY > 10)
Anxiety symptoms 1497 - 13.87 13.83 25,647+
interacted with In(odds) of horse h in that race. We used In(odds) because (GAD7 > 10))
this better captures the non-linear nature of odds. Self-reported 2404 - 23.65 22.00 3436
As when modelling choice of race, Model 1 in the analysis of horse diagnosis of anxiety
did not include observed preference heterogeneity. Model 2 added or depression
Any Mental Health 34,62 3393 3243 5128+
mental health variables, here interacted with In(odds) and all attribute Problem
levels. Demographics
Model 3 included both mental health and problems due to gambling. 18-35 3613 4405 3458 3878 42.56*
As with choice of race, sensitivity analyses were conducted. Male 5007 37.45% 5359 5545+ 559
Less than $40,000 2026 3611 2757% 2494 2564
Gambling
3. Results Participated in 8571 BL7S* 9021 9433t 1007
gambling in last 12
3.1. Sample ‘months
Ever Gambled on 8420 8254 - 1004+ 92,824
Horse Racing
Completed surveys were received from 728 participants. 114 people Ever Gambled Online 6058 56.75 7194~ 76414
indicated that they both had not and would not gamble online, and on Horse Racing
hence were screened out and did not complete the survey. Note that the
Problems due to 2679 39.68% 2053t 3379%*
gambling (PGSI >
final sample includes people who have not gambled online but indicated 2)
that they would gamble online. Survey Difficulty
No participants were removed based on their responses. Although Easy 4038 3452 43.07 43.99 3897
some DCE studies remove participants who provide straight-line re- Neither 4492 4841 44.54 46.03 4872
sponses (i.e. choose the same alternative in every choice set) or complete Difficult 1470 17.06% 1240 998%* 1231
L. Cameron and J. Ride Social Science & Medicine 326 (2023) 115885

mental health problem. Consistent with existing literature, people with racing before.
mental health problems were more likely to be 35 and under, female, Less than 15% of the sample stated that they found the survey
have lower incomes (e.g. see Pich et al. (2020) and Rosenfield and difficult. People with mental health problems on average found the
Mouzon (2013)), and were less likely to participate in gambling but survey more difficult. People who had gambled on horse racing before
more likely to be experiencing problems due to gambling (Rockloff et al., and gambled online on horse racing before overall found the survey less
2020). People who had gambled on horse racing before were more likely difficult.
to be older than 35, male, and have an income higher than $40,000.
People who had gambled online on horse racing before were more likely
3.2. Model estimates
to be male and have incomes higher than $40,000. Roughly half of the
people experiencing problems due to gambling also had a mental health 3.2.1. Choice of race
problem (51.28%). People experiencing problems due to gambling were ‘Table 3 presents the results of the correlated random coefficients
more likely to be 35 and under and to participate in gambling and have ‘mixed logit models examining choice of race. A higher coefficient in-
gambled on horse racing and online on horse racing before.
Table A4 in the online appendix provides descriptive statistics by age dicates a greater preference for betting on a given race. Model 1 presents
the results when only including the ASC (including block interactions),
and gender jointly. 35 and under females had the highest proportion of main effects, and two-way attribute interactions. Model 2 includes all
people with a mental health problem. 35 and under males had the mental health interactions in addition to Model 1, and Model 3 includes
highest proportion of people who had gambled online on horse racing problems due to gambling in addition to Model 2. See supplementary
before and who were experiencing problems due to gambling. Over 35
material for the results of the two-way attribute and ASCXblock in-
males had the highest proportion of people who had gambled on horse teractions. The model is effects coded and hence the coefficients of the

Table 3
Mixed logit models estimating choice of race, with correlated random parameters to account for scale. Model 1 is when only including ASC, main effects, and attribute
and block interactions. Model 2 includes mental health interactions. Model 3 includes mental health and PG interactions. Coefficients are effects coded. Clustered
standard errors are presented. Two-way attribute intera ions and ASCXblock were also included in the model - see supplementary material for the coefficients of these
variables. * indicates the statistical significance of the difference of the coefficients from zero: *p < 0.05, **p < 0.01, ***p < 0.001. For tips and inducements, t
indicates the statistical significance of the difference of the coefficients from no tip and no inducement respectively: tp < 0.05, ttp < 0.01, tttp < 0.001.
Attribute Level Model 1 sD Model 2 sD Model 3 sD
Mean Mean Mean
ASC 1.89 014 1.96 017 2.06 0.16
Race 0dds No favourite, spread ~0.04 ~0.05 ~0.08
No favourite, even 009 013 002 013 0.06 0.14
Favourite, spread 0.05 017 0.01 017 0.05 017
Favourite, even 0.08 012 0.08 012 0.06 012
Time 10 min ~0.04 ~0.06 ~0.03
3 min 0.04 007 0.06 0.07 0.03 0.07
Form Form not provided 0.01 0.06 012
Form provided ~0.01 011 ~0.06 011 -0.12 011
Tip No tip 0.30 036 0.25
Tip on favourite 019t 013 021t 014 0.22¢ 014
“Tip on 3rd favourite 011 018 015 018 0.03 018
Inducement No inducement ~0.70%++ ~0.66%* —0.52++
Money back special 0,61+ trt 013 0,66+ ttt 014 0.51% tt 013
Increased odds 0.09 ttt 012 0.00tt 013 0.01 ¢ 013
Interactions MHPXASC 0.28* 012 ~0.05 0.09
MHPXNo favourite, spread 011 011
MHPXNo favourite, even 0.01 0.06 0.02 0.07
MHPXFavourite, spread ~0.02 0.07 ~0.01 0.07
MHPXFavourite, even ~0.09 0.06 ~0.12 0.07
MHPX10 min 001 ~0.01
MHPX3 minutes ~0.01 0.03 0.01 0.03
MHPXForm not provided 0.08 0.07
MHPXForm provided 0.08" 0.04 0.07 0.04
MHPXNo tip 002 ~0.04
MHPXTip on favourite ~0.01 0.06 0.05 0.06
MHPXTip on 3rd favourite ~0.01 0.06 ~0.01 0.06
MHPXNo inducement 005 0.03
MHPXMoney back special ~0.07 0.07 ~0.03 0.07
MHPXIncreased odds 0.02 0.07 0.00 0.07
PGXASC 0.27+ 0.10
PGXNo favourite, spread ~0.09
PGXNo favourite, even 0.05 0.07
PGXFavourite, spread ~0.03 0.08
PGXFavourite, even 0.07 0.07
PGX10 min 0.06
PGX3 minutes 0.06 0.04
PGXForm not provided 0.08
PGXForm provided ~0.08* 0.04
PGXNo tip 0214+
PGXTip on favourite ~0.14% tt 0.06
PGXTip on 3rd favourite ~0.07t 0.06
PGXNo inducement 0,25
PGXMoney back special ~0.24% e 0.08
PGXIncreased odds —0.01t 0.08
L. Cameron and J. Ride Social Science & Medicine 326 (2023) 115885

levels within each attribute sum to zero. The table presents the statistical
significance of the difference of the coefficients from zero (the average of
that attribute’s coefficients). For the tips and inducements attributes, it
is more meaningful to compare their coefficient with the coefficient of
the base level (i.e. no tip and no inducement respectively). Therefore, for
these attributes, Table 3 also presents the statistical significance of the
difference of the coefficients from the coefficient of the base level. The
odds attribute does not have a clear base level and hence we do not
present the statistical significance of the difference of the coefficients of
the odds attribute from a base coefficient. Since ASC, form, and time are
dichotomous, significance levels for these are identical whether
compared with a base level or zero. We consider results as strong evi-
dence of choices being influenced if the p-value (measure of statistical
significance) is below 0.05.
All models show that the marketing strategies influenced choice.
This is seen with a positive coefficient relative to no marketing strategy.
The race odds, whether horse’s form was provided, how long until the
race starts, and an expert tip on the third favourite were not significant
predictors of the choice of race.
Model 2 suggests that people with mental health problems were
more likely to bet on one of the races (positive coefficient on ASC
interaction) and had a lower preference for races with horse's form
provided. Preferences for marketing strategies, race odds, and the time
until the race starts, did not differ significantly for people with mental
health problems.
Model 3 suggests that people experiencing problems due to gambling
were more likely to bet on one of the races (positive coefficient on ASC
interaction) and had a lower preference for races with horse's form
provided, tips, and inducements. Preferences for race odds and time
until the race starts did not differ significantly for people experiencing
problems due to gambling.
Comparing the coefficients on the mental health interactions be-
tween Models 2 and 3, the mental health interaction with the ASC is not
significant in Model 3 (and the coefficient now negative). This indicates
that the finding in Model 2 that people with mental health problems
were more likely to bet on one of the races is driven by people with
‘mental health problems being more likely to be experiencing problems
due to gambling, which is associated with the higher likelihood of
betting on one of the races. It is also noted that, in Model 3, the finding
that people with mental health problems have a lower preference for
races with form is not significant at the 5% level as it is in Model 2.
However, given the similar coefficient between Models 2 and 3 (-0.08
and —0.07 respectively), and the p-value only marginally greater than
0.05 in Model 3 (p = 0.056), this does not greatly undermine the finding
from Model 2.
3.2.2. Choice of horse
Table 4 presents the results of the models examining choice of horse.
A higher coefficient indicates a greater preference for betting on a horse
with higher odds.
All models show that people preferred betting on horses with lower
odds - horses that are more likely to win but have a lower potential
payoff. This was particularly true for races with form provided and when
there was an expert tip predicting the favourite to win. The time until the
race starts and whether the race has an inducement did not significantly
affect the odds of the horse chosen.

Table 4
Mixed logit models estimating choice of horse, with correlated random parameters to account for scale. Model 1 is when only including In(odds) (including block
interactions), main effects and two-way attribute interactions. Model 2 includes mental health interactions. Model 3 includes mental health and PG interactions.
Coefficients are effects coded. Clustered standard errors are presented. Two-way attribute and In(odds)Xblock interactions were also included in the model - see
supplementary material for the coefficients of these variables. * indicates the statistical significance of the difference of the coefficients from zero.
Attribute Level Model 1 5D Model 2 sD Model 3 sD
Mean Mean Mean
In(0dds) ~0.56++ 0.03 —0.53++ 0.04 —0.51+++ 0.04
Time In(0dds)X10 min 002 002 002
In(0dds)X3 minutes ~0.02 0.03 ~0.02 0.03 ~0.02 0.03
Form In(0dds)XForm not provided 0.06 0.06 0.06
In(0dds)XForm provided ~0.05* 0.02 ~0.06* 0.03 ~0.06* 0.03
Tip In(0dds)XNo tip 01440 0154+ 0154+
In(0dds)XTip on favourite ~0.19+** tt 0.03 ~0.19+** tt 0.03 ~0.19** tt 0.04
In(0dds)XTip on 3rd favourite 0.05 ut 0.04 0.04 ut 0.03 0.04 ut 0.03
Inducement In(0dds)XNo inducement ~0.02 ~0.01 ~0.02
In(0dds)XMoney back special 003 0.03 003 0.03 004 0.04
In(0dds)Xincreased odds ~0.01 0.03 ~0.02 0.03 ~0.02 0.04
Interactions MHPXIn(0dds) 012 0.04 011+ 0.04
MHPXIn(Odds)X10 min 0.00 001
MHPXIn(Odds)X3 minutes 0.00 0.03 0.01 0.02
MHPXIn(Odds)XForm not provided ~0.01 ~0.01
MHPXIn(Odds)XForm provided 0.01 0.03 0.01 0.02
MHPXIn(0dds)XNo tip 005 005
MHPXIn(0dds)XTip on favourite 0.00 0.03 001 0.03
MHPXIn(Odds)XTip on 3rd favourite 0.05 0.03 005 0.03
MHPXIn(Odds)XNo inducement 004 004
MHPXIn(Odds)XMoney back special 0.01 0.03 0.00 0.03
MHPXIn(Odds)Xincreased odds ~0.04 0.03 ~0.04 0.03
PGXIn(0dds) 005 0.04
PGXIn(0dds)X10 min 001
PGXIn(Odds)X3 minutes 0.01 0.02
PGXIn(Odds)XForm not provided 0.01
PGXIn(Odds)XForm provided ~0.01 0.02
PGXIn(0dds)XNo tip 0.01
PGXIn(0dds)XTip on favourite ~0.02 0.04
PGXIn(0dds)XTip on 3rd favourite 0.01 0.04
PGXIn(0dds)XNo inducement ~0.01
PGXIn(Odds)XMoney back special 001 0.03
PGXIn(Odds)XInereased odds 0.00 0.03
*p <0.05, **p < 0.0, ***p < 0.001. For tips and inducements, t indicates the statistical significance of the difference of the coefficients from no tip and no inducement
respectively: tp < 0.05, ttp < 0.01, tttp < 0.001.
L. Cameron and J. Ride Social Science & Medicine 326 (2023) 115885

Models 2 and 3 suggest that people with mental health problems gambled on horse racing and who did not find the survey difficult, but
preferred betting on horses with higher odds compared to people was a smaller magnitude of coefficient when only including people who
without mental health problems. In terms of the odds of the horse they had gambled online on horse racing before (although the coefficient
bet on, people with mental health problems did not respond differently remained negative).
depending on the time until the race starts, whether a race has horse’s Note that betting on horse racing is highly normalised in Australia, so
form provided, expert tips, or inducements. people may be familiar with the environment presented in the survey
Model 3 did not show any significant differences for the preference of even if they have not gambled online on horse racing before. These
horse’s odds between people with and without problems due to findings indicate that the preferences for people with mental health
gambling. problems may differ depending on if they have gambled online before,
but that this is not due to a lack of understanding of the environment.
3.3. Sensitivity analyses The result that people with mental health problems have a preference
for horses with higher odds, relative to people without mental health
A total of 12 sensitivity analyses were conducted. Table 5 presents a
problems, remained statistically significant across all models.
A second set of sensitivity analyses included each of the three mea-
summary of the coefficients and statistical significance from each of the
analyses for the two key results regarding mental health: (i) lower sures of mental health problems individually in separate models rather
preference for races with form when analysing choice of race and (ii) than in a combined single variable as in the main analysis. This was to
greater preference for horses with higher odds when analysing choice of explore any differences in preferences between the measures. For these,
horse. These coefficients are from models controlling for problems due
the result regarding preference for races with form was similar to the
to gambling (as in Model 3 of the main analysis). Sample sizes are ‘main analysis for people who self-reported as having a diagnosis of
depression and/or anxiety. The point estimate remained negative in the
provided. Numbers in parentheses indicate the table in the online ap-
pendix where full results can be found.
‘models using the measures of depression and anxiety based on the PHQ9
One set of sensitivity analyses restricted the sample based on
and GAD7 respectively, but these were a smaller magnitude. These
gambling experience in three ways: including only people who have differences might suggest that having a history of diagnosed depression
gambled on horse racing before, including only people who have and/or anxiety is driving this result more so than current symptoms. The
gambled online on horse racing before, and excluding people who stated result that people with mental health problems have a preference for
they found the survey difficult. This was to explore whether people’s horses with higher odds, relative to people without mental health
understanding of the survey environment influenced responses. The
problems, was similar across the three analyses. The statistical signifi-
cance was lower than in the main analysis, but this was likely due to
result regarding preference for races with form for people with mental
health problems was similar to the main analysis for people who had lower statistical power rather than differences in preferences.
A third set of sensitivity analyses changed the cut-off point of the
mental health variable. This was to explore whether the severity of
Table 5
mental health problems impacted responses. For these, respectively, a
Coefficients and statistical significance from the sensitivity analyses of (i) the person was defined as having mental health problems if: (i) PHQ9 > 15
mental health and form interaction when analysing choice of race and (ii) the
mental health and In(Odds) interaction when analysing choice of horse. All (severe symptoms of depression), GAD7 > 15 (severe symptoms of
models included PG interactions, as in Model 3 of the main analysis. * indicates anxiety), and/or self-reported diagnosis of anxiety and/or depression,
the statistical significance of the difference of the coefficients from zero: “p < (i) PHQO > 5 (mild or higher symptoms of depression), GAD7 > 5 (mild
0.05, **p < 0,01, ***p < 0.001. Sample sizes are provided. Numbers in paren- or higher symptoms of anxiety), and/or self-reported diagnosis of anx-
theses indicated the table in the online appendix where the full results can be iety and/or depression, (i) at least two of PHQ9 > 10, GAD7 > 10, and/
found. or self-reported diagnosis of anxiety and/or depression. The result
Choice of race Choice of regarding preference for races with form was similar to the main anal-
horse ysis when changing the cut-off points for the PHQ9 and GAD? to severe
MHPXForm MHPXIn or mild rather than moderate. The result disappeared when defining a
provided (0dds) mental health problem as meeting the criteria for at least two of the
Main analysis, N = 728 ~0.07 011+ individual measures. These results indicate that the greatest difference
Experience of gambling in preferences is between people with no mental health problems and
Have gambled on horse racing before, N = ~0.09* 012 any mental health problem. The result that people with mental health
613 (A7, A10) problems have a preference for horses with higher odds, relative to
Have gambled online on horse racing before, ~0.01 011+ people without mental health problems, was fairly consistent across the
N = 441 (A8, A11)
Did not find the survey difficult, N = 621 (A9, ~0.08 02+ three models.
A12) Another sensitivity analysis included MHP x PG interactions in
Individual mental health measures addition to Model 3. This was to explore whether differences in pref-
PHQO > 10, N = 728 (A13, A16) ~0.04 009 erences for people with mental health problems was dependant on their
GAD7 > 10, N = 728 (A14, A17) ~0.03 0.09 PG status. The two key results were similar to in the main analysis. None
Self.reported diagnosis of anxiety and. or 0.09" 008
depression, N = 728 (A15, A18) of the MHP x PG interaction terms were statistically significant (see
Different mental health measure cutoffs Tables A25 and A26 in online appendix), indicating differences in
PHQ9 & GAD7 > 15 (severe), N = 728 (A19, —0.09* 007 preferences for people with mental health problems was not dependant
A22) on their PG status.
PHQO & GAD? > 5 (mild/moderate/severe), ~0.07 009"
N =728 (A20, A23) A final set of sensitivity analyses excluded people who could be
Two or three measures of mental health 0.00 011+ considered to have given inattentive responses. Respectively, these two
problems, N = 728 (A21, A24) analyses excluded people: (i) that gave straight-line responses and (ii
Interaction between MHP and PG included in the model had a completion time in the bottom 10% of the main sample suggesting
N = 728 (A25, A26) ~0.07 o1
Removing potentially inattentive responses that they may be rushing through the survey rather than considering
Excluding straight-line responses, N = 627 0.08* 011+ each choice set. The two key results were similar to the main analysis for
(A27, A29) each of these.
Excluding completion time in bottom 10%, N ~0.07 009"
= 655 (A28, A30)
L. Cameron and J. Ride
4. Discussion
This study implemented a Discrete Choice Experiment to analyse
what influences people’s choice of race and horse when gambling online
on horse racing. Broadly, there were two key findings. First, people with
mental health problems were found to have different preferences for
both their choice of race and choice of horse. Second, there was evidence
that marketing strategies can increase the frequency that people bet.
4.1. Mental health problems
Relative to people without mental health problems, we found that
people with mental health problems have a lower preference for betting
on races with horse’s form provided and prefer betting on horses with
higher odds, robust to controlling for problems due to gambling. These
two findings could have important implications for understanding why
people with mental health problems are more likely to experience
problems due to gambling.
One possible explanation for people with mental health problems
having a lower preference for races with form is that they are more likely
to gamble as escape. The result that people with mental health problems
prefer betting on horses with higher odds suggests they place riskier bets
and hence are more risk seeking. People who use gambling as an escape
are likely to gamble more regularly and people who place riskier bets
have a higher probability of losing their bets, both of which can result in
greater total expenditure on gambling. Therefore, these are two
gambling characteristics that may lead to developing problems due to
gambling, and have been linked to gambling harm in surveys of
gambling behaviour (Flack and Morris, 2015; Wichler and Peters, 2015).
Our finding that these characteristics are more prominent in people with
mental health problems suggests two plausible mechanisms by which
people with mental health problems may be more likely to develop
problems due to gambling. This is consistent with epidemiological evi-
dence of higher rates of people experiencing problems due to gambling
in this group.
The explanation that a lower preference for form may be due to
gambling as an escape is consistent with a study suggesting that a state
of absorption when playing electronic gaming machines is particularly
enjoyable for people with depression (Dixon et al., 2019) and that
gambling as an escape may mediate the relationship between depression
and experiencing problems due to gambling (Vaughan and Flack, 2022).
However, our finding regarding riskier bets is contrary to a study which
found evidence that people with anxiety are less risk seeking (Char-
pentier et al., 2017). One explanation for this may be that risk prefer-
ences differ between contexts. Charpentier et al. (2017) elicited risk
preferences using a standard gamble without the context of gambling on
horse races online. The Charpentier study relates to monetary outcomes
but does not incorporate other attributes. Factors such as the excitement
of the race may bring different framing effects which alter the rela-
tionship between anxiety and risk.
Our findings suggest two possible mechanisms to explain the higher
rates of problems due to gambling among people with mental health
problems: they may be more likely to gamble as an escape and place
riskier bets. These results imply that policy responses to help reduce the
risk of experiencing problems due to gambling for this already disad-
vantaged population could be (i) promoting less harmful activities
which also act as an escape and (ii) policies targeting ‘risky” bets (those
with a low probability of winning and high potential payoff) such as
advertising restrictions, reduced access, or an awareness campaign.
Improving people’s mental health to reduce the need for an escape may
be the optimal outcome. However, mental health problems are pervasive
and increasingly common, suggesting the need for harm minimization
strategies. If promoting less harmful activities which act as an escape (e.
g. physical exercise or exploring nature) can reduce the need for people
to use gambling as an escape then it could help to reduce gambling harm
for people with mental health problems. This is a similar approach to
Social Science & Medicine 326 (2023) 115885
that of the “100 Day Challenge™ (2020) (https://www.100dc.com.au/),
which is tailored for people experiencing problems due to gambling. The
100 day challenge suggests activities for people to do in place of their
gambling. Our results suggest that a similar approach among people
with mental health problems might also be valuable. Regarding (i),
specific bets are regularly advertised on television before or during
sports matches or racing carnivals. The bets that these advertisements
promote are commonly risky bets (Newall et al., 2019b). Given our
finding that these types of bets are more attractive for people with
mental health problems, these advertisements may disproportionately
influence this population.
4.2. Marketing strategies
The results found that people prefer betting on races with an
inducement (money back special or increased odds) or an expert tip
predicting the favourite to win. These results imply that expert tips and
inducements can increase the frequency at which people bet. This is
consistent with existing studies using self-reported survey data (Browne
etal., 2019; Hing et al., 2019). On each race, the average gambler has an
expected loss (Levitt, 2004). Therefore, these results suggest that offer-
ing expert tips and inducements s likely to increase people’s monetary
loss. The caveat to this is that the money back special improves the
expected payoff for gamblers, and hence it may be rational to bet on
races with this inducement. However, people often overestimate the
benefit of these inducements (Hing et al., 2017b). Therefore, even with
this inducement, gambling more often likely increases the amount that
people lose. By increasing the frequency that people bet, these market-
ing strategies likely contribute to risk of developing problems due to
gambling. The findings regarding choice of horse imply that the in-
ducements, on average, did not influence the riskiness of the bet. This is
consistent with self-reported survey data indicating that, of people who
claimed to be influenced by these inducements, a similar percentage
placed riskier bets as placed safer bets (Hing et al., 2019).
We found no differences in responsiveness to marketing strategies for
people with mental health problems, and a lower responsiveness for
people experiencing problems due to gambling. This may imply that
these marketing strategies predominantly affect low-risk people. How-
ever, the marketing strategies did still increase the frequency at which
people experiencing mental health problems and problems due to
gambling bet (although not to the extent of people not experiencing
problems due to gambling). Further, this study captured choice of event
and item, and marketing strategies may have greater influence on people
experiencing mental health problems and problems due to gambling for
other gambling choices, such as the decision to open a gambling account
or begin a session of betting. For example, a study measuring pupil
dilation when exposed to inducements found that they elicited a greater
desire to gamble in people experiencing problems due to gambling (Lole
et al., 2020).
The result that inducements and expert tips increase the frequency in
which people bet (and thereby increase risk of experiencing problems
due to gambling) supports greater restrictions on these types of mar-
keting strategies to reduce rates of people experiencing problems due to
gambling.
4.3. Limitations
One limitation of this study is that it only captures the choices of
which event and item to bet on in the context of online gambling on
horse racing. Choices such as the betting platform, the gambling activ-
ity, the amount bet, and the type of bet were fixed in our survey, unlike
in a real-world setting. However, gamblers may pre-determine these
choices when gambling, and hence only exploring what influences the
choice of race and horse bet maintains real-world applicability. Another
limitation is that there was no incentive compatibility (i.e. participants
did not receive the results of their bets in monetary outcomes), which
L. Cameron and J. Ride
may affect the external validity of the results. A third limitation is that
the high correlation between the three measures of mental health
problems made it difficult to conduct analysis that aimed to distinguish
between them. There are differences in the three measures, and hence
they may have different associations with gambling behaviour, but we
were unable to explore these differences adequately with our sample.
Fourth, we describe gambling more frequently and a lower preference
for form as signs of gambling as an escape, but there are other possible
explanations. Wanting to gamble more frequently may instead by due to
greater enjoyment of gambling or greater impulsivity. A lower prefer-
ence for form could instead be due to a lower cognitive ability to process
information or a lower belief that form is useful information in pre-
dicting which horse will win. Despite other possible explanations, we
still believe these attributes provide some evidence for gambling as an
escape. Finally, the data collected was cross-sectional. Therefore,
although we could control for problems due to gambling when exploring
choices for people with mental health problems, we do not know the
sequence of developing mental health problems and these behavioural
differences. Similarly, although associations have been established in
existing literature, there is limited causal evidence for the impact of
these gambling behaviours on gambling harms. We propose them as
plausible pathways by which people with mental health problems are
more likely to develop problems due to gambling, rather than inferring
that mental health problems cause gambling harms via these behav-
ioural patterns.
5. Conclusion
This study provides information on how features of races and horses,
such as marketing strategies, influence gambling choices. We also pro-
vide information on how gambling characteristics differ for people with
mental health problems and how this may influence their likelihood of
developing problems due to gambling. This is important for informing
policy and interventions to reduce the risk of gambling harm for the
general population and people with mental health problems specifically.
This study has also exhibited the feasibility of conducting a DCE to
capture these sorts of gambling choices, which can open a field of
research to explore gambling behaviour further.
Credit author statement
Lachlan Cameron: Conceptualization, Methodology, Formal anal-
ysis, Investigation, Data curation, Writing — Original Draft, Visualiza-
tion, Funding acquisition. Dr Jemimah Ride: Conceptualization,
Methodology, Investigation, Writing — Review & Editing, Supervision,
Funding acquisition.
Data availability
‘The authors do not have permission to share data.
Acknowledgements
The authors acknowledge the funding support from the Victorian
Responsible Gambling Foundation and the Melbourne Social Equity
Institute. Without their support this project would not have
possible. The Victorian Responsible Gambling Foundation provided
input into the study design including the design of choice sets and the
wording used. The interpretation of data and opinions presented in this
study are that of the authors, and do not necessarily reflect opinions of
either funding source.
‘The authors also wish to thank the advisory committee for their input
into the design of the research and the interpretation of results. The
advisory committee was made up of Kate Scalzo and Rosa Billi (VRGF),
John Pethick, Ingrid Ozols, and Paula O'Brien, Jeannie Patterson, and
Jonathon Liberman (Melbourne Law School).
‘Social Science & Medicine 326 (2023) 115885
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
0rg/10.1016/j.socscimed.2023.115885.
References
100 Day Challenge, 2020. Retrieved. hitps://www.100dc.com.au/. (Accessed 4 October
2022).
Blaszezynski, A., Nower, L., 2002. A pathways model of problem and pathological
gambling. Addiction 97 (5), 487-499.
Browne, M., Bellringer, M., Greer, N., Kolandai-Matchett, K., Langham, E., Rockloff, M.,
Du Preez, K., Abbott, M., 2017. Measuring the Burden of Gambling Harm in new
zealand.
Browne, M., Hing, N., Russell, A.M., Thomas, A., Jenkinson, R., 2019. The impact of
expostre to wagering advertisements and inducements on intended and actual
betting expenditure: an ecological momentary assessment study. J. Behav. Addict. 8
(1), 146-156.
Calado, F., Griffiths, M.D., 2016. Problem gambling worldwide: an update and
systematic review of empirical research (2000-2015). J. Behav. Addict. 5 (4),
592-613.
Charpentier, C.J., Aylward, J., Roiser, J.P., Robinson, 0.J., 2017. Enhanced risk aversion,
but not loss aversion, in unmedicated pathological anxiety. Biol. Psychiatr. 81 (12),
1014-1022.
ChoiceMetrics, 2018. Ngene 1.2.1. http://www.choice-metrics.com/.
Columb, D., 0°Gara, C., 2018. A national survey of online gambling behaviours. Ir. J.
Psychol. Med. 35 (4), 311-319.
Dixon, M.J., Gutierrez, J., Stange, M., Larche, C.J., Graydon, C., Vintan, 5., Kruger, T.B.,
2019. Mindfulness problems and depression symptoms in everyday lfe predict dark
flow during slots play: implications for gambling as a form of escape. Psychol
Addict. Behav. 33 (1), 81.
Dussault, F., Brendgen, M., Vitaro, F., Wanner, B., Tremblay, R.E., 2011. Longitudinal
links between impulsivity, gambling problems and depressive symptoms: a
transactional model from adolescence to early adulthood. JCPP (J. Child Psychol.
Psychiatry) 52 (2), 130-138,
Effertz, T., Bischof, A., Rumpf, H.-J., Meyer, C., John, U., 2018, The effect of online
gambling on gambling problems and resulting economic health costs in Germany.
Eur. J. Health Econ. 19 (7), 967-978.
Feris, J.A., Wynne, H.J,, 2001. The Canadian Problem Gambling Index. Canadian Centre
on substance abuse Ottawa, ON.
Flack, M., Morris, M., 2015. Problem gambling: one for the money. J. Gambl. Stud. 31
(4), 1561-1578,
Flack, M., Stevens, M., 2019. Gambling motivation: comparisons across gender and
preferred activity. Int. Gambl. Stud. 19 (1), 69-84.
Gainsbury, SM., Russell, A., 2015. Betting patterns for sports and races: a longitudinal
analysis of online wagering in Australia. J. Gambl. Stud. 31 (1), 17-32.
Hess, ., Train, K., 2017. Correlation and scale in mixed logit models. J. Choice Model.
23,18
Hing, N., Russell, A.M., Browne, M., 2017a. Risk factors for gambling problems on online
electronic gaming machines, race betting and sports betting. Front. Psychol. 8, 779,
Hing, N., Sproston, K., Brook, K., Brading, R., 2017b. The structural features of sports and
race betting inducements: issues for harm minimisation and consumer protection.
J. Gambl. Stud. 33 (2), 685-704
Hing, N., Russell, AM., Thomas, A., Jenkinson, R., 2019. Wagering advertisements and
inducements: exposure and perceived influence on betting behaviour. J. Gambl,
Stud. 35 (3), 793-811
Kjaer, T., 2005. A Review of the Discrete Choice Experiment-With Emphasis on its
Application in Health Care.
Kroenke, K., Spitzer, R.L., Williams, J.B., 2001. The phq-9: validity of a brief depression
severity measure. J. Gen. Intern. Med. 16 (9), 606-613.
Lamers, F., van Oppen, P., Comijs, H.C., Smit, J.H., Spinhoven, P., van Balkom, A.J.,
Nolen, W.A., Zitman, F.G., Beckman, A.T., Penninx, B.W., 2011. Comorbidity
pattems of anxiety and de- pressive disorders in a large cohort study: The
Netherlands study of depression and anxiety (nesda). J. Clin. Psychiatry 72 (3),
3397.
Lancaster, K.J., 1966. A new approach to consumer theory. J. Polit. Econ. 74 (2),
132-157.
Lancsar, E., Louviere, J., 2006. Deleting ‘irrational'responses from discrete choice
experiments: a case of investigating or imposing preferences? Health Econ. 15 (8),
797-811.
been Lancsar, E., Fiebig, D.G., Hole, A-R., 2017. Discrete choice experiments: a guide to model
specification, estimation and software. Pharmacoeconomics 35 (7), 697-716.
Levitt, $.D., 2004. Why are gambling markets organised so differently from financial
‘markets? Econ. J. 114 (495), 223-246.
Livingstone, C., Rintoul, A., 2020. Moving on from responsible gambling: a new
discourse is needed to prevent and minimise harm from gambling. Publ. Health 184,
107-112.
Lole, L., Russell, AM, Li, E., Thome, H., Greer, N, Hing, N., 2020. Interest in
inducements: a psychophysiological study on sports betting advertising. Int. J.
Psychophysiol. 147, 100-106.
Mora-Salgueiro, J., Garcia-Estela, A., Hogg, B., Angarita-Osorio, N., Amann, BLL.,
Carlbring, P, Jimenez- Murcia, §., Perez-Sola, V., Colom, F., 2021. The prevalence
and clinical and sociodemographic factors of problem online gambling: a systematic
review. J. Gambl. Stud. 1-28,
1
L. Cameron
and J. Ride
Newall, P.W., Moodie, C., Reith, G., Stead, M., Critchlow, N., Morgan, A., Dobbie, F.,
2019a. Gambling marketing from 2014 to 2018: a lterature review. Curr. Addiction
Rep. 6 (2), 49-56.
Newall, P.W., Thobhani, A., Walasek, L., Meyer, C., 2019b. Live-odds gambling
advertising and consumer protection. PLoS One 14 (6), 0216876.
Perini, G., Ramusino, M.C., Sinforiani, E., Bernini, S., Petrachi, R., Costa, A., 2019,
Cognitive impair- ment in depression: recent advances and novel treatments,
Neuropsychiatric Dis. Treat. 15, 1249-1258.
Pieh, C., Budimir, ., Probst, T., 2020. The effect of age, gender, income, work, and
physical activity on mental health during coronavirus disease (covid-19) lockdown
in Austria. J. Psychosom. Res. 136, 110186.
Revelt, D., Train, K., 1998. Mixed logit with repeated choices: households’ choices of
appliance efficiency level. Rev. Econ. Stat. 80 (4), 647-657.
Rockloff, M., Moskovsky, N., Thorne, H., Browne, M., Bryden, GM., 2017.
Environmental factors in the choice of egms: a discrete choice experiment. J. Gambl.
Stud. 33 (3), 719-734.
Rockloff, M., Browne, M., Russell, A.M, Hing, N, Greer, N., 2019. Sports betting
incentives encourage gamblers to select the long odds: an experimental investigation
using monetary rewards. J. Behav. Addict. 8 (2), 268-276.
Rockloff, M., Browne, M., Hing, N., Thorne, H., Russell, A., Greer, N., Tran, K., Brook, K.,
Sproston, K., 2020. Victorian Population Gambling and Health Study 2018-2019.
Victorian Responsible Gambling Foundation, North Melbourne, Australi
Rosenfield, S., Mouzon, D., 2013. Gender and mental health. In: Handbook of the
Sociology of Mental Health. Springer, pp. 277-296.
Roth, L., 2020. Gambling: an Update. NSW Parliamentary Research Service.
Russell, AM., Browne, M., Hing, N., Rockloff, M., Newall, P., 2022. Are any samples
representative or unbiased? reply to pickering and blaszezynski. Int. Gambl. Stud. 22
(1), 102-113.
12
Social Science & Medicine 326 (2023) 115885
Schellenberg, B.J., McGrath, D.5., Dechant, K., 2016. The gambling motives
questionnaire financial: factor structure, measurement invariance, and relationships
with gambling behaviour. Int. Gambl. Stud. 16 (1), 1-16.
Soekhai, V., de Bekker-Grob, E.W., Ellis, AR., Vass, C.M., 2019. Discrete choice
experiments in health economics: past, present and future. Pharmacoeconomics 37
(2), 201-226.
Song, H., Wang, J., Lyu, 5.0., 2021. Willingness to pay for casino-based integrated
resorts: a choice experiment. J. Destin. Market. Manag. 19, 100555.
Spitzer, R.L., Kroenke, K., Williams, J.B., Lowe, B., 2006. A brief measure for assessing
generalized anxiety disorder: the gad-7. Arch. Intern. Med. 166 (10), 1092-1097.
Stanton, R., To, Q.G., Khales, S., Williams, S.L., Alley, 5.J., Thwaite, T.L., Fenning, A.S.,
Vandelan- otte, C., 2020, Depre ty and stress during covid-19:
associations with changes in physical activity, sleep, tobacco and alcohol use in
Australian adults. Int. J. Environ. Res. Publ. Health 17 (11), 4065.
‘Taoka, D., Kusumi, T., 2021. Role of affect and risk-benefit perception on reckless
betting: prior wins and losses both lead to risky bets. J. Gambl. Stud. 1-25.
Teichert, T., Graf, A., Swanton, T.B., Gainsbury, 5.M., 2021. The joint influence of
regulatory and social cues on consumer choice of gambling websites: preliminary
evidence from a discrete choice experiment. Int. Gambl. Stud. 1-18.
Vaughan, E., Flack, M., 2022. Depression symptoms, problem gambling and the role of
escape and excitement gambling outcome expectancies. J. Gambl. Stud. 38 (1),
265-278.
Wiehler, A., Peters, J., 2015. Reward-based decision making in pathological gambling:
the roles of risk and delay. Neurosci. Res. 90, 3-14.
Wood, R'T., Griffiths, M.D., 2007. A qualitative investigation of problem gambling as an
escape-based coping strategy. Psychol. Psychother. Theor. Res. Pract. 80 (1),
107-125.
Yang, Y., Hobbs, J.E., 2020. How do cultural worldviews shape food technology
perceptions? evidence from a discrete choice experiment. J. Agric. Econ. 71 (2),
465-492.