“High Stakes: Gambling Addiction, Beyond Borders” is a three-part series looking at the public health movement to address gambling in Massachusetts and the United States, and what can be learned from two countries with very different models of gambling regulation: Norway and the United Kingdom. This is part one of that series.
A gambling arcade in Oslo, Norway, couldn’t be further in mood from, say, the MGM Springfield casino. The Norwegian betting place — on the second floor of an urban strip mall — looks more like a sterile office suite compared to the rows of clanging, flashing slot machines and roulette tables found in U.S.-style resort casinos.
People sit in faux leather chairs in front of silent computer terminals, playing casino games or bingo, or watching a horse race on TV with the sound down low.
Bjorn Helge Hoffman types in his government ID number to play blackjack on one of the machines. He starts out betting 2 kroner – roughly 20 cents.
“I could increase it to five crowns per spin,” he said.
Like all Norwegian residents, Hoffman, who runs the responsible gaming division for the state-owned company Norsk Tipping, is only allowed to lose a certain amount per month — called a “loss limit.” Legally, the maximum is 20,000 kroner, or about $2,000. But he’s picked a lower number: around $100.
After the on-screen graphics spin for a few moments, the display lets him know he won 30 kroner. But you can hardly tell. There are no bells, no manufactured sounds of coins falling into a steel bowl.
“All those sounds are meant to make you play more,” he said.
So it’s hard to get excited by the win, and that’s the point. Norway has developed an industry out of tamping down the impulsivity of gambling. It has rejected many of the features that target the brain’s reward systems: fast and chaotic games, greater odds, bigger payouts and higher risk.
The government limits not just the style and pace of games but the amount of time and money Norwegians can spend gambling.
At the same time, “there is an inherent discussion on how much regulation should the state have and how much liberty should its citizens have, and where is the balance between these,” said Charlie Thompson, a researcher at the Norwegian University of Science and Technology who specializes in global gambling policy.
This question has been dogging policy leaders around the world as gambling expands rapidly, with the potential of both greater revenue and mental health harms. Earlier this year, a report published in The Lancet, a medical journal, called on international health leaders to act quickly on regulations before gambling disorders become endemic, making it hard to put the genie back into the bottle.
This debate is happening across the United States, too.
Ever since the U.S. Supreme Court legalized sports betting in 2018, the country’s gambling industry has exploded. Thirty-nine states now allow online sports betting. That’s on top of the other forms of gambling now allowed in 48 states, from lotteries and land-based casinos to online casino games. The American Gaming Association estimated that Americans spend more than $100 billion yearly on legal sports bets, including $3 billion on this year’s March Madness alone.
And Massachusetts — which has legalized most forms of gambling except online casino games — ranks number one in the country in lottery spending and in the top 10 for casino gambling and online sports betting.
So it’s not surprising that UMass Amherst researchers estimate 10% of the state’s population has either developed — or is at risk for — gambling disorders, from mild compulsion to full blown addiction.
Today, the primary, industry-led approach to gambling disorders in the United States is called “responsible gaming.” It offers a mix of warning messages (“Got a problem?”) on buses or billboards, as well as gambling helplines, treatment referrals and the option to “self-exclude” from betting spaces.
But a growing movement of mental health advocates and political leaders say that approach is too weak and focused on individual behavior to take on the onslaught of advertising, promotions and sheer opportunity to bet 24/7. They want to see a preventive, public health approach in which the government regulates the industry across the board to lessen harm for everyone.
And they’re looking at regions like Norway where this model is underway.
“How much can you afford to lose?”
Massachusetts has been hailed by U.S. health leaders for its attention to problem gambling. When casinos were first legalized here in 2011, the state law directed a portion of industry profits to research and prevention of problem gambling. Massachusetts also set up a state gambling commission to grant licenses and enforce rules.
But compared to Norway, Massachusetts is practically the wild west.
When it comes to gambling, Norway is one of the most regulated countries in the world. The gambling industry is run almost entirely by the government itself — one of the only countries with a state monopoly.
“Being owned by the state gives us the opportunity to focus on the main goal to prevent problem gambling,” Hoffman said. His employer, Norsk Tipping, oversees all of Norway’s online sports betting, online casino games, lottery, and land-based slot machines. (Norway does not allow brick-and-mortar casinos.)
Norsk Tipping’s approximately 2 million customers all use a government-issued ID so their betting can be tracked as part of what is essentially a harm reduction approach to gambling.
Hoffman said everyone must make a choice before they even start to play: “How much can you afford to lose in the cold light of the day?”
Jonny Engebo, a policy advisor for the Norwegian Gambling Authority, said the country’s regulations assume that anyone is vulnerable to addiction.
“You can look at them [as] airbags,” he said. “So if it gets really bad, you will not have so severe consequences that you cannot, in a way, carry on with your life.”
Engebo’s research suggests the rate of gambling addiction in Norway is lower than many other countries and going down. According to 2022 data, 0.6% of the population are considered problem gamblers. That’s less than a third of the rate estimated in the United States.
“It’s working,” said Erlend Hanstveit, state secretary in Norway's Ministry of Culture and Equality, who oversees much of the gambling industry. “We are moving in the right direction.”
How Norway got here
It didn’t used to be this way.
As recent as the early 2000s, just before internet gambling took off, slot machines were everywhere in Norway — supermarkets, airport lounges, convenience stores. Even ferries taking commuters between the country’s many fjords had them.
“So while you were on the ferry going from A to B, well, there was only one thing you could do. You could play the slot machines,” health advocate Magnus Pedersen said.
Today, Pedersen works for an advocacy organization called Gambling Addiction Norway. Its founder, Lill-Tove Bergmo, started the organization as a 20-something mother who discovered that her husband — a truck driver — lost their family’s money on truck-stop slot machines.
After her husband entered treatment, she began to call on legislators to get rid of the slots.
At the time, Pedersen said, many people didn’t understand that behaviors can be as addictive as substances. In addition to financial ruin, people with gambling disorders have high rates of depression, anxiety and even suicide, with serious impact on friends and family as well. Pedersen said gamblers often go into a sort of bubble.
“And in the bubble, it's just you and the gambling, every stress, every problem you have, everything else just goes away,” he said. “But as with any other short term solution, after a while, it's not enough.”
As more families began to speak out, lawmakers decided they had to do something. In 2007, the government ordered the removal of all slot machines that had been operating in public places.
Magnus Eidem, an addiction specialist with the treatment organization Bla Kors (Blue Cross), worked for the country’s gambling helpline at the time.
“And what happened? Quiet on the helpline,” he said. “Suddenly, no one called.”
Eidem said gambling support group members would cry with relief “because they were so happy they could go to the store and buy milk and bread without having to fight their way through the hallway with 10 slot machines.”
When online gambling and smartphone apps arrived, the government had to pivot again, adapting the same time and money limits to the electronic space.
Norway has also banned VIP schemes, loyalty programs and betting bonuses, all of which encourage more gambling. There’s no sports betting after a game has started. And gambling company staff reach out to players who, according to their tracked activity, seem to be heading into trouble. (See Sidebar: Betting on the Horses: A Norwegian Case Study.)
“In general, Norwegians are much more tolerant towards these invasive policy tools,” said Thompson, the Norwegian gambling researcher. He notes that public support is also high because all gambling profits go to charities, public institutions and local sports teams. “Sure, some might want more freedom,” he said, “but in general it's not a salient issue.”
“Do it the right way for the place”
The gambling debate in Norway is different from other parts of the world, including the United States, where politicians focus more on individual freedom and have less appetite for regulation.
In Massachusetts, the state gaming commission has put in measures that allow players to voluntarily set time and spending limits. But Mark Vander Linden, who oversees “responsible gaming” for the commission, doesn't think U.S. regulators or players would tolerate mandatory limits.
“The commission is certainly monitoring what's happening in other countries,” Vander Linden said. “There's been a lot that has been tried. Sometimes it can work really well in a country and fall flat in another country.”
However, he said “there are ways in which we can more proactively reach out to patrons and provide them with very specific information about their actual gambling behavior.”
Hoffman, the Norsk Tipping leader, said he often meets gambling regulators who claim strict Norwegian-style rules and spending limits would never work in an individualistic country like the United States.
“But then I challenge them, ‘Why not?’” Hoffman said. “Because everything changes all the time. I think people have a different view on safety in cars now than they had 20 years ago. And I think people have a different view on how to use health apps and training apps. So it’s just a matter of — do it the right way for the place.”
“The Norwegian rules are a bit silly, if you ask me”
Norway has seen some pushback to its strict approach.
At an Oslo sports pub called Bohemen, where soccer games are blaring on the TV, a 40-year-old bartender named Nimo Gasparim was serving drinks while checking his phone. He said he’s been gambling since he was 18.
“To be honest, the Norwegian rules are a bit silly, if you ask me,” Gasparim said.
Gasparim said he doesn’t like to be told how much money he can lose. And he doesn’t appreciate the restrictions over what times he can gamble in Norway, especially since he likes to bet on U.S. ice hockey games that are in a different time zone. So he goes on foreign gambling websites that are illegal in Norway and have no limits at all.
“I know that it's not healthy,” Gasparim said. “I could have saved all the money that I've spent all these years, but I do it because I think it's fun.”
At another sports bar called Wild Rover, a bartender named Ryan was on his phone using a "virtual private network," or VPN, to get around Norway’s ban on foreign gambling sites.
“Why do you think other people are going to all these other betting services outside of Norway?” he said. “Because there's better offers, there's better sign-up deals, there's more weekly deals. You'll be getting boosts, you're getting free bets for certain markets.”
Magnus Eidem, the addiction specialist, says the foreign gambling sites are much more likely to lead to gambling disorders than the legal market; the more money people lose through unregulated play, the more they try to gamble it back. That includes young people who find foreign sites before they’re old enough to legally gamble.
“Now they contact us with a severe gambling problem, and they're not even done with school,” Eidem said.
The government says it’s doing its best to shut down the illegal gambling industry. For instance, banks are not allowed to transfer money to, or from, the foreign companies, and the gambling authority is working on blocking their websites.
But since many illegal companies are still getting through, Hoffman said Norsk Tipping has been developing more exciting games to compete against foreign sites, though with slower speeds and lower stakes.
“It doesn't help if you have the best responsible gaming framework or measures in the world if no one wants to play with you,” Hoffman said.
But some critics say you can’t have it both ways.
“That's a dangerous road to walk,” said Pedersen, the Gambling Addiction Norway advocate. “I don't think you can make gambling products more attractive without making them more dangerous, because it's the nature of the product.”
Erlend Hanstveit, the Norwegian state secretary, said they really have no choice but to walk this delicate line.
“The Norwegian company will never have the best odds on a football match, for example,” he said. “But it will be able to compete with the international [market]. So if you get three times your money back by an international betting company, maybe you get 2.9 in the Norwegian company. And we think that is good enough.”
The future of Norway’s gambling experiment is uncertain, however, depending in part on who wins the national election in the fall. The conservative party in Norway — in concert with the Norwegian Online Gaming Industry Association — has been advocating to end the state monopoly on gambling and to open the market up to private license holders. That would bring Norway much closer to the rest of the world.
Next up in the series: While Norway limited access to gambling in the mid-2000s, the United Kingdom did the opposite — legitimizing an industry that had previously been merely tolerated. Public health leaders across the Atlantic say the United States should take note of the challenges the U.K. has faced since gambling spread to almost every city.
This project was supported by a grant from the Association of Health Care Journalists, with funding from The Commonwealth Fund. It was edited by Dusty Christensen, with help from Elizabeth Roman.