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Can you ‘nudge’ your way out of ‘fixed odds betting’?
Left to its own devices, can the unfettered market be good for your health?
The period of office for the coalition so far, neoliberal in flavour, has seen a number of examples where various industries have found, it is alleged, a sympathetic ear from the Conservative and Liberal Democrats in government. But the question is: are these parties now making a difference to your health, to its detriment?
Not long after the start of the discussion of standard cigarette packaging, and amidst of continuing talk of concerns of the level of sugar in processed foods, politicians and the media have turned to ‘fixed odds betting terminals’. Many see the ’24 hour drinking culture’, a policy plank of a previous New Labour administration, to have been left a largely negative longstanding legacy with some vulnerable individuals.
The ‘cost of living crisis’ is a very clever way for Ed Miliband to introduce a much wider issue. Far from the market being liberalising, the market is in fact producing unreasonable fetters on us, it is argued. Neoliberal proponents do not obviously wish to tout the notion that a free market is in fact bad for your health.
Fixed odds betting terminals were launched in 1999, after then chancellor Gordon Brown scrapped tax on individual bets in favour of taxing bookmakers’ profits. It depends of course where you draw the line with these ‘pleasurable activities’. Drinking socially is an altogether different phenomenon to drinking a bottle of vodka for breakfast to overcome withdrawal symptoms. Just as drinking is legal, some forms of betting are legal, and all Governments have taxed them. The traditional argument is that this tax revenue can contribute to funding health and social care services, including ‘new innovative’ ways of treating addiction.
High stakes casino-style gambling was banned from High Streets, but fixed odds betting terminals used remote servers so that the gaming was not taking place on the premises. After the Gambling Act [2005], fixed odds betting terminals were given legal backing, and put under the same regulatory framework as fruit machines. They stopped using remote servers but stakes were limited to £100 and terminals to four per betting shop. Punters could place a £100 stake every 20 seconds. According to the Gambling Commission there are 33,284 fixed-odds betting terminals across the UK. The number of betting shops in the UK has increased from 8,500 to 9,100 over the past two years, with hundreds more planned. Unlike traditional fruit machines in pubs and amusement arcades, punters can gamble up to £100 every 20 seconds on fixed odds betting terminals, attracted by payouts of up to £500.
It is said that most people gamble at some point in their lives, but for some gambling can become a serious addiction. For the vast majority of people, gambling entails putting a bet on a sports match now and again or entering the weekly lottery draw. However, for a small proportion of gamblers, betting and playing games to win money can become a serious addiction, which can spiral out of control and affect their professional and social lives. In the UK, it is estimated that around 350,000 people are suffering from a gambling addiction. In recent years, the number of people experiencing problems with gambling has increased due to economic troubles associated with the global recession and an increase in the number of gambling outlets, it is thought.
There are some hints if you end up answering ‘yes’ to any of these questions: Do you take time off work to gamble? Are you in debt? Do you prioritise gambling over your family/friends/work/hobbies? Do you lie to others about your financial situation? Do you think about gambling a lot? Does your loved one become defensive or embarrassed when you ask them about gambling? Do they make excuses or lie about where they have been or how much money they have spent? Are they becoming increasingly secretive about money? Do they hide bank statements or leave them unopened? Ultimately, people who’ve fallen victim to a ‘fixed odds betting addiction’ will demonstrate the cardinal features of all addictive behaviours: tolerance to getting the ‘high’, and the need to avoid bad withdrawal symptoms from continued problem addictive behaviour.
Conversely, the “nudge” or, more formally, libertarian paternalist approach has been high on the political agenda during the period of the currrent Government. The reason for the political popularity of nudging is that offers politicians a tool by which they can offer guidance, without enforcement, on individual behaviour change that is good for and, on reflection, preferred by, individuals themselves. Various nudge policies have been proposed to tackle obesity, and it is useful perhaps to consider why or how these have not worked well either.
Whilst there are few overt ‘physical’ symptoms or signs compared to other addictions (such as weight/addiction to food, cirrhosis/addiction to alcohol), you can easily piece together an explanation for why all is not quite ‘normal’ with the human body. In 1998, Koepp and colleagues published a very famous paper in Nature (May 21;393(6682):266-8) arguing evidence for “striatal dopamine release during a video game.” Signalling in the brain and brainstem using the chemical ‘dopmaine’ may be involved in learning, reinforcement of behaviour, attention, and sensorimotor integration. The authors found evidence that endogenous dopamine is released in the human striatum during a goal-directed motor task, namely a video game.
A “pleasure centre” was discovered in the 1950s by two brain researchers named James Olds and Peter Milner who were investigating whether rats might be made uncomfortable by electrical stimulation of certain areas of their brain. In this work and work arising from this, the “nucleus accumbens” (NAcc) was found to be linked to the rewarding of human behaviours. The human brain and the cluster of NAcc brain cells partner together to provide these clues by releasing chemicals. The two main chemicals that are released into the NAcc upon certain stimulation are dopamine and serotonin. Dopamine is the neurotransmitter that increases the desire for that stimulant. Stimulants have been found to include sex and drugs of addiction as ‘reinforcers’, and money can be viewed as a ‘higher order reinforcer’ as money in theory can buy you sex or drugs or addiction for example.
In a Commons debate in which Labour demanded tougher curbs on high street “mini-casinos”, ministers promised measures to protect gamblers later this year after a Government review. The pledge came as the Government comfortably defeated a Labour motion calling for councils to be given power to limit the number of high-stake fruit machines by 314 to 232, a majority of 82. Despite the large Government majority, some Tory MPs backed calls for urgent action and a small number of Coalition back benchers are thought to have abstained. In a Commons vote last month, four Tory MPs voted against the Government and supported Labour in its calls for the stakes on the so-called fixed odds betting terminals to be slashed from £100 to £2.
For decades, the neoliberal protagonists have derided the law and regulation as ‘adding red tape’, obstructing the market. Nonetheless, legislative statutory instruments have made it to the statute books, such as regulation for air quality. In the same way that there is perhaps ‘responsible capitalism’ (though there are some who reject capitalism altogether so find the idea of responsible capitalism predictably an oxymoron), there is perhaps growing acceptance that the State can intervene in protecting its citizens. This is after all what Ed Miliband and Labour is attempting to do with energy bills, for example. You can choose to approach gambling addictions in much the same way as other addictions are managed psychologically (for example through the ’12 steps program’ with individuals admitting first “powerlessness” over their gambling behaviours). There are other valid approaches too. Or you can tackle fixed odds betting, and the causes of fixed odds betting.
If I could predict the future of my health, would I change my behaviour?
A major issue in economics certainly is how individuals cope with information. Much information is uncertain, so one’s ability to make rational decisions based on irrational information is a fascinating one. Predicting the future may be viewed as best kept as the bastion of astrologers such as Mystic Meg, but the likelihood of future outcomes is clearly of interest in the insurance industry. These decisions are not only helpful for people at an individual basis, but also hopefully useful for planning, rather than predicting, what is best for the population at large in future.
Angelina Jolie did not have cancer, but, in fact, like many women with breast cancer mutations, she had the radical surgery to lower her risk. She, at the age of 37, has described her decision as “My Medical Choice,” in an op-ed in the New York Times. She carries the BRCA1 gene mutation, which gives her an 87% risk of developing breast cancer at some point in her life. The abnormal gene also increases her risk of getting ovarian cancer, a typically aggressive disease, by 50%. To counteract those odds, Jolie wrote that she decided to have both her breasts removed. In 2010, Australian scientists found that women with the BRCA1 or BRCA2 mutations who chose to have preventive mastectomies did not develop breast cancer over the three-year follow-up. Since the genetic abnormalities increase the risk of ovarian cancer, women who had their ovaries and fallopian tubes removed also dramatically lowered their risk of developing ovarian or breast cancers. The ability of medicine to predict one day, with relative certainty, the likelihood to develop certain conditions is an intriguing way, and leaves the open the possibility of ‘personalised medicine’ on the basis of your own individual information. If you think the NHS is already overstretched, with A&E closures contributing to the ‘crisis’ in emergency health provision, then footing a bill for personalised medicine might be the ‘straw that breaks the camel’s back’. The idea that one day you can predict the likelihood of a person developing multiple sclerosis or Alzheimer’s Disease still intrigues neurologists.
This furthermore presents formidable challenges for the law. In recent years, governments have been embracing policies that ‘nudge’ citizens into making decisions that are better for their own health and welfare, including our own Government which has decided to ‘mutualise’ its own ‘Nudge Unit’. The European Commission has embraced this ‘libertarian paternalism’ in its review of the Tobacco Products Directive. Various people has recently explained that by introducing measures such as plain packaging and display bans, the European Union may be able to ‘nudge’ people into smoking less, whilst preserving their right to choose. After having relied on the assumption that governments can only change people’s behaviour through rules and regulations, policy makers seem ready to design polices that better reflect how people really behave. Inspired by “libertarian paternalism,” the nudge approach suggests that the goal of public policy should be to steer citizens towards making positive decisions as individuals and for society while preserving individual choice.
It’s likely that a ‘one glove fits all’ policy is not going to work. About a decade ago, I was surrounded in my day job by individuals with hepatic cirrhosis, requiring abdominal paracentesis to tap away fluid from their tummies. And yet being confronted with people yellow due to the build-up of bilirubin did not deter me one jot from being a card-carrying alcohol. I am not over seventy months in recovery from alcohol misuse, so this aspect of how people make decisions before being addicted intrigues me. I think that people genuinely in addiction ‘can’t say stop’, as they don’t have an off-switch; they lack insight, and are in denial, mostly, I feel from personal experience.
It’s also clear that there is a long-list of medical problems that cause someone to present to an A&E department aside from alcohol, such as a sore-throat, faint, dislocated shoulder, and so on. But alcohol is undeniably a big issue, so the question is a sobering one, pardon the pun. To what extent can we ‘nudge’ people out of alcohol-related illness? Commenting on the report out today from the College of Emergency Medicine, that highlights the pressures that Accident and Emergency (A&E) wards are under, Dr John Middleton, Vice President for Policy at the Faculty of Public Health, said:
“We quite rightly have high expectations of doctors and nurses working in emergency medicine, so it’s only fair that they get the support they need to do their jobs safely and well. One way to reduce the burden on Accident and Emergency (A&E) wards would be to tackle the reasons why people are admitted in the first place: in particular, alcohol. Given that drink related violence accounts for over one million A&E visits every year, we urgently need the government to be bold and introduce a minimum price per unit of alcohol. That would reduce the burden on overstretched hospitals and society as a whole.”
Nobody likes assessing risk, especially the consequences of an addict picking up/using again are potentially catastrophic even if in probability terms theoretically infinitesimally low. People who know about Taleb’s “Black Swan” work will know this well. And assessing harm has led others to be blasted in the public arena previously, for example Prof David Nutt who once compared the dangers of horse riding to the dangers presented by the major drugs of abuse. At a time when both the medical and legal professions at least think there should be an open debate about having ‘another look’ at the Misuse of Drugs Act (1971), hopefully a public can welcome a mature debate on this.
Even today, the news reports that introducing a law to force cyclists to wear helmets may not reduce the number of hospital admissions for cycling-related head injuries.Researchers said that while helmets reduce head injuries and should be encouraged, the decrease in hospital admissions in Canada, where the law is in place in some regions, seems to have been “minimal”. The authors examined data concerning all 66,000 cycling-related injuries in Canada between 1994 and 2008 – 30% of which were head injuries. Writing in the British Medical Journal, the authors noted a substantial fall in the rate of hospital admissions among young people, particularly in regions where helmet legislation was in place, but they said that the fall was not found to be statistically significant.
I suppose all political parties desire people with capacity to make decisions about their own lifestyle and healthcare, very much in keeping with the ‘no decision about me without me’ philosophy currently in vogue. If push came to shove, if I could predict the future of my health, would I fundamentally change my behaviour? Probably within reason, but the only thing which I am pretty certain about is having another alcoholic drink may lead to a pattern of behaviour that will ultimately kill me.
If I could predict the future of my health, would I change my behaviour?
A major issue in economics certainly is how individuals cope with information. Much information is uncertain, so one’s ability to make rational decisions based on irrational information is a fascinating one. Predicting the future may be viewed as best kept as the bastion of astrologers such as Mystic Meg, but the likelihood of future outcomes is clearly of interest in the insurance industry. These decisions are not only helpful for people at an individual basis, but also hopefully useful for planning, rather than predicting, what is best for the population at large in future.
Angelina Jolie did not have cancer, but, in fact, like many women with breast cancer mutations, she had the radical surgery to lower her risk. She, at the age of 37, has described her decision as “My Medical Choice,” in an op-ed in the New York Times. She carries the BRCA1 gene mutation, which gives her an 87% risk of developing breast cancer at some point in her life. The abnormal gene also increases her risk of getting ovarian cancer, a typically aggressive disease, by 50%. To counteract those odds, Jolie wrote that she decided to have both her breasts removed. In 2010, Australian scientists found that women with the BRCA1 or BRCA2 mutations who chose to have preventive mastectomies did not develop breast cancer over the three-year follow-up. Since the genetic abnormalities increase the risk of ovarian cancer, women who had their ovaries and fallopian tubes removed also dramatically lowered their risk of developing ovarian or breast cancers. The ability of medicine to predict one day, with relative certainty, the likelihood to develop certain conditions is an intriguing way, and leaves the open the possibility of ‘personalised medicine’ on the basis of your own individual information. If you think the NHS is already overstretched, with A&E closures contributing to the ‘crisis’ in emergency health provision, then footing a bill for personalised medicine might be the ‘straw that breaks the camel’s back’. The idea that one day you can predict the likelihood of a person developing multiple sclerosis or Alzheimer’s Disease still intrigues neurologists.
This furthermore presents formidable challenges for the law. In recent years, governments have been embracing policies that ‘nudge’ citizens into making decisions that are better for their own health and welfare, including our own Government which has decided to ‘mutualise’ its own ‘Nudge Unit’. The European Commission has embraced this ‘libertarian paternalism’ in its review of the Tobacco Products Directive. Various people has recently explained that by introducing measures such as plain packaging and display bans, the European Union may be able to ‘nudge’ people into smoking less, whilst preserving their right to choose. After having relied on the assumption that governments can only change people’s behaviour through rules and regulations, policy makers seem ready to design polices that better reflect how people really behave. Inspired by “libertarian paternalism,” the nudge approach suggests that the goal of public policy should be to steer citizens towards making positive decisions as individuals and for society while preserving individual choice.
It’s likely that a ‘one glove fits all’ policy is not going to work. About a decade ago, I was surrounded in my day job by individuals with hepatic cirrhosis, requiring abdominal paracentesis to tap away fluid from their tummies. And yet being confronted with people yellow due to the build-up of bilirubin did not deter me one jot from being a card-carrying alcohol. I am not over seventy months in recovery from alcohol misuse, so this aspect of how people make decisions before being addicted intrigues me. I think that people genuinely in addiction ‘can’t say stop’, as they don’t have an off-switch; they lack insight, and are in denial, mostly, I feel from personal experience.
It’s also clear that there is a long-list of medical problems that cause someone to present to an A&E department aside from alcohol, such as a sore-throat, faint, dislocated shoulder, and so on. But alcohol is undeniably a big issue, so the question is a sobering one, pardon the pun. To what extent can we ‘nudge’ people out of alcohol-related illness? Commenting on the report out today from the College of Emergency Medicine, that highlights the pressures that Accident and Emergency (A&E) wards are under, Dr John Middleton, Vice President for Policy at the Faculty of Public Health, said:
“We quite rightly have high expectations of doctors and nurses working in emergency medicine, so it’s only fair that they get the support they need to do their jobs safely and well. One way to reduce the burden on Accident and Emergency (A&E) wards would be to tackle the reasons why people are admitted in the first place: in particular, alcohol. Given that drink related violence accounts for over one million A&E visits every year, we urgently need the government to be bold and introduce a minimum price per unit of alcohol. That would reduce the burden on overstretched hospitals and society as a whole.”
Nobody likes assessing risk, especially the consequences of an addict picking up/using again are potentially catastrophic even if in probability terms theoretically infinitesimally low. People who know about Taleb’s “Black Swan” work will know this well. And assessing harm has led others to be blasted in the public arena previously, for example Prof David Nutt who once compared the dangers of horse riding to the dangers presented by the major drugs of abuse. At a time when both the medical and legal professions at least think there should be an open debate about having ‘another look’ at the Misuse of Drugs Act (1971), hopefully a public can welcome a mature debate on this.
Even today, the news reports that introducing a law to force cyclists to wear helmets may not reduce the number of hospital admissions for cycling-related head injuries. Researchers said that while helmets reduce head injuries and should be encouraged, the decrease in hospital admissions in Canada, where the law is in place in some regions, seems to have been “minimal”. The authors examined data concerning all 66,000 cycling-related injuries in Canada between 1994 and 2008 – 30% of which were head injuries. Writing in the British Medical Journal, the authors noted a substantial fall in the rate of hospital admissions among young people, particularly in regions where helmet legislation was in place, but they said that the fall was not found to be statistically significant.
I suppose all political parties desire people with capacity to make decisions about their own lifestyle and healthcare, very much in keeping with the ‘no decision about me without me’ philosophy currently in vogue. If push came to shove, if I could predict the future of my health, would I fundamentally change my behaviour? Probably within reason, but the only thing which I am pretty certain about is having another alcoholic drink may lead to a pattern of behaviour that will ultimately kill me.
