Why are Australians so addicted to sports betting?

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Intro: This podcast was made on the lands of the Wurundjeri people, the Woi Wurrung and the Bunurong. We pay our respects to their elders, past and present, and to emerging leaders. From the University of Melbourne's School of Psychological Sciences, this is PsychTalks.

Cassie: Welcome back. Today we're talking about alcohol use, impulsivity, and why some people move from casual drinking to dependence while others don't. We sometimes think of addiction as a matter of self-control or willpower, but what if the story is more about how we respond to reward, learn from consequences, and think about the future?

We're joined by Dr Antoinette Poulton to talk about her research on impulsivity, feedback, and how simple insights into their behaviour might help people change their relationship with alcohol.

Nick: Antoinette is a researcher at the University of Melbourne whose work focuses on the brain's executive functions and how they relate to substance use and addiction.

Her research explores why some people are more vulnerable to developing problematic alcohol use and how real-time feedback and digital tools can support behaviour change. Her work spans experiments, digital and pharmacological interventions, and app-based studies that track people's cognition and behaviour in everyday life.

Antoinette, welcome to PsychTalks. So let's start with how you got into research in this area. Was it a straight path or a winding one?

Antoinette: Well, thanks so much for having me on PsychTalks. My research journey has been an incredibly winding path, in fact, I started my professional career in teaching. When I first started teaching in Australia, I was teaching English language to new arrivals, to migrants, to refugees, and also to international students. And then I spent some time teaching abroad. I worked in mainstream secondary schools supporting young people with learning difficulties. Basically I was helping them access the mainstream curriculum and respond to it.

Then I had this extraordinary teaching experience in Spain. I was employed by a research institute attached to the Polytechnic University of Valencia.

And their research focused on thermodynamics, thermofluids, and they had these very lucrative contracts with um European automotive companies, and my students essentially were working on those contracts, and they needed help to um express their results more fluently in English, so I was employed, to work with them so that they could speak more clearly and, and more quickly and fluently.

But they were all PhD students in engineering, physics, and maths, and during this time I witnessed a very different attitude to drugs than I had seen as a young person in Australia. My students were very high achieving, high performing individuals.

Many had already won very prestigious national awards in their field, but they were nonetheless engaging in, at least by Australian standards, a fairly serious recreational drug use. It wasn't uncommon for them to turn up on a Monday morning and to tell me about how they'd been high on this or that across the weekend, but they'd front up to work on Monday, perfectly functional, they'd engage in highly technical work successfully.

And yeah, it was a little bit unusual. I'd not witnessed that before in Australia, and, and in general really in Spain, the people I interacted with had a very relaxed attitude to drug taking, there was less stigma and certainly around recreational drug use anyway. So early on when I was still thinking my career would be in teaching, I was developing this curiosity around different attitudes to drugs and what constituted addiction.

When I returned to Australia after about 5 years, I actually continued teaching, and again I was supporting young people in mainstream schools with learning issues, but after a while I started to get very bored, very restless, and I thought, well, a way to combat that would be to do some psychology subjects. I thought maybe I could look at the neurobiology underpinning some of the disorders I saw in my students.

So I started taking some undergraduate psychology subjects, and basically I got hooked very quickly. Within 6 months, I'd quit school or quit work as a teacher, and I'd come to the University of Melbourne. I was doing the graduate diploma in psychology. And during that time, it was sort of during the 3rd year subjects that I counted Professor Rob Hester, and he was doing a series of lectures on addiction and what constituted addiction, and I got very, very interested. It recalled my experiences in Spain.

And so really from that point on, one thing led to another very quickly. I did my 4th year with Rob as supervisor and then undertook a PhD a couple of years later, also with Rob as supervisor.

Cassie: So a lot of your recent research is about drinking and especially what you call hazardous alcohol use. So it'd be interesting just to talk about what you define hazardous use. Is it a binge on the weekend? Is it a clinical addiction? Is it something else? Is it different here than in Spain?

Antoinette: Yeah, well, hazardous alcohol use actually is defined by the World Health Organization. And it involves three core components or core elements. It refers to consumption, so basic quantity, frequency questions around how much we're drinking, and that can include binge drinking questions. It also includes symptoms of dependence, so for instance, struggling to stop drinking once you've started, functional difficulties that we might experience that I didn't see in Spain, and alcohol related problems like guilt, blackout, if someone's perhaps alerted you to their concerns about your drinking.

So it's essentially hazardous alcohol use is essentially a pattern of behaviour that increases an individual's risk for physical or psychological harm, even if you don't actually yet see those consequences. They may emerge later, and it's linked to an increased risk of acute injuries like falls or car accidents or being the perpetrator or victim of violence, greater likelihood of developing chronic illness like liver disease or other cancers related to alcohol.

And critically, this type of alcohol use renders people much more vulnerable for developing alcohol use disorders or dependence. So hazardous use is different to addiction, but it can be considered, at least for some people, a bit of a precursor to the development of alcohol use disorder. Now, in Australia, we actually use, we assess consumption using national drinking guidelines which currently state that um anyone who drinks more than 10 standard drinks a week or 4 drinks in one day is at greater risk of harm.

But the guidelines do emphasise that actually there's no level of drinking that's completely safe. Recent national surveys in Australia, so these are surveys conducted by the Australian Institute of Health and Welfare, and we've got a big national survey that comes out every 2 to 3 years, the National Drug Strategy Household Survey, that shows that about 1 in 3 Australians are drinking above those Australian guidelines, and if we look at the group of people under the age of 25, it's about 40% exceed those guidelines.

Cassie: And there's been some recent news about kids or young people these days drinking less, so is, is hazardous drinking in Australia a bigger problem for younger people than perhaps we're seeing in the news?

Antoinette: It's true that younger people on average are drinking less, but it's the same amount of alcohol there are still this group, this sub-cohort of young people who are drink that are keeping the level, the amount of drinking elevated. I think just recently, yesterday or the day before actually,

Some results came out about the biggest group of drinkers are now men in their middle age. It's definitely true that we see that group at the moment engaging in greater frequency and quantity of drinking.

But yeah, generally drinking is done by the sort of hazardous drinking or drinking above guidelines is done by a relatively small number of people, but they're drinking a lot, and that's certainly the case for younger people, and, and causing some harmful consequences.

Nick: I, yeah, yep. I'll have to look out for that when I enter middle age. So one idea that's really front and centre in your scientific work, Antoinette, is this idea of impulsivity, so what do you mean by that?

Antoinette: So broadly we're, we can think about impulsivity as acting on the spur of the moment or acting quickly, perhaps too quickly without thinking things through or thinking about consequences. In the research arena, impulsivity is understood to be multi-dimensional, and there are two aspects that are particularly relevant in the area of addiction or addiction research, that's impulsive decision-making and response inhibition.

Impulsive decision making refers to that tendency some of us have to favour immediate rewards regardless of what’s the outcome, and if we put that another way, that's sensitivity to proximate or close reward and insensitive, insensitivity to the delayed consequences.

And we're exhibiting this type of impulsivity when we choose to keep drinking because it feels good, rather than to consider how it might impact our ability to perform it at our job tomorrow or how it might affect our long-term health. Response inhibition by contrast is thought of as self-control. It's our ability to think through the consequences and to inhibit or stop ourselves from drinking in the moment.

Nick: Got it, so a combination of sort of rushing into things too quickly without thinking about long-term consequences and not resisting or delaying gratification?

Antoinette: Exactly, that's exactly right, and the theory suggests that impulsivity will emerge when there's an imbalance between those two aspects of impulsive, you know, impulsive decision making versus the um inhibitory control processes.

Cassie: It reminds me of another episode we've got this season with Daniel Bennett around gambling, and I guess gambling goes hand in hand with alcohol use both in kind of behaviours but also this impulsivity. Can you tell us a little bit about the brain processes or the mental functions that are responsible for impulsivity?

Antoinette: Yeah, sure, so impulsive decision making is thought to be mediated by reward sensitive, dopamine rich mid-brain areas, and we're talking about several areas here. People have probably heard of the amygdala, which processes emotion.

And biases decision making toward emotionally charged immediate responses, we're talking about the insular as well, which is linked to craving, that sort of feeling we must have it now. The ventral striatum is also involved, which is a key area for reward-processing and risk-taking. Response inhibition by contrast is underpinned by more top-down processes, so it falls under the overarching umbrella of executive function.

And inhibition in fact is a core element of executive function. Our executive functions are those higher order skills that enable us to plan, to organise, to enact self-control, to remember, keep things in mind, our working memory, to shift attention, to adjust, our behaviour in response to changing circumstances, and these functions are mediated by the prefrontal cortex.

Response inhibition in particular is supported by the dorsolateral prefrontal cortex, and that's an area where we hold long-term goals in mind, such as, I need to stay sober.

Nick: So, does being more impulsive make you more likely to start using alcohol in hazardous ways, or more likely for your hazardous use to progress further, or what?

Antoinette: Yeah, well this is really interesting because there is quite a raft of evidence that suggests pre-existing impulsivity renders individuals more vulnerable for problems with alcohol and or drugs, so impulsive decision making and or response, poor response inhibition in children and young adults predicts an earlier onset of first alcohol or drug use.

It also predicts a rapid escalation of use, so for instance, from occasional use to heavy use, but we also know though that alcohol and drug use can exacerbate impulsivity, and there's sort of two arms to this type of research. There are acute effects, so when under the influence, people tend to be more impulsive, and people who had pre-existing higher levels of impulsivity will be even more impulsive in the moment once they've taken some alcohol or drugs on board.

But there's also, with chronic use, we see structural and functional changes in the brain, and it's those brain regions I mentioned involved in decision making and self-control, which can produce then even greater heightened impulsive behaviour, so it's sort of a feedback loop starts to develop.

It's worth mentioning that there's evidence that the changes we see in the brains related to decision making and response inhibition are especially prominent in young people who commence alcohol and drug use quite early. So there's a bit of research around young people who commence drinking sort of at around 15, and we see long-term changes in their brain.

Cassie: So you're talking about people having differences in impulsivity from a starting point. So if we know impulsivity is a risk factor for problematic alcohol use, how do we change that?

Antoinette: Yeah, so there's a bit of research going on in this area at the moment and different research groups are taking different approaches. Impulsivity does appear to have biological underpinnings.

Nonetheless, it's important to remember, that being impulsive doesn't mean someone will definitely develop problems with drug or alcohol, it's just that they appear to be more vulnerable.

So it might be of benefit to intervene in these cases, to be able to target these people with early interventions, early education, maybe some skill building, and I guess it's probably beneficial to think in terms of managing and reducing the impact of impulsivity rather than categorically being able to change it.

Cassie: Would someone know if they're high on impulsivity?

Antoinette: Well, they may do. One arm of research just asks self-report questions about impulsivity, so it's possible to, you know, go online and have a look. But I mean, in testing people, certainly a number of people will indicate to me prior to testing, “oh I think I'm more impulsive than most people”, yeah.

Nick: Yeah, it's so interesting cos when you think about impulsiveness from a personality perspective, it just suggests this is something that you have or something that you are and you're not really gonna change it very much, so, what do you do about it?

But I think what's interesting about your work is you're thinking about impulsiveness as something that you can not necessarily overcome, but, but there are clever tricks that you can get around it if you like, or to offer a more optimistic, if you like, stance towards recovery.

So one thing that you've done in your work which I think is fascinating, is this idea that simply giving people feedback about their drinking can result in reductions in hazardous alcohol use. So can you explain what you've done on this topic?

Antoinette: Yeah, absolutely. So we've conducted two studies now with two different samples, and the results have shown that if we provide people with personalised information about their drinking, about their level of impulsivity, and how impulsivity is implicated in hazardous alcohol use, they appear to reduce their drinking.

So in one study we found that young hazardous drinkers had reduced their total intake at follow-up, which was at about 60 days, by 32 to 35%, which is equivalent to 4 standard drinks per week. And so this was in response to this feedback, that group of young people, there was 250 of them, and they're 21, 22 years of age.

The impact on their drinking was so substantial that these hazardous drinkers couldn't be distinguished from non-harmful drinkers at follow-up, and this was on measures of total intake, on binge drinking, on how much people would drink in any one day. We could no longer define them as hazardous drinkers. We've recently replicated this study in a larger multi-part study which is about to come out in JMIR, and in this study we follow people at 3 months, and again we see a 33% reduction in drinking.

Cassie: Does that feedback only reduce the drinking for those who feel they have a problem or who want to reduce it, that have some motivation to drink less when they find out how much they're drinking, or, can anyone kind of see a reduction in their drinking even if they don't have that kind of desire or motivation to drink less?

Antoinette: Well, you would think that motivation might be a key factor, but that's not actually what we saw in our results. We were looking in this second study to see if we could see what was underpinning this reduction in drinking, and motivation was one of the variables that we included, but this didn't seem to have any impact on the actual change, which was actually a surprising finding.

There are some large meta-analysis studies that have come out of the United States recently that that do question whether motivation's an essential element for this kind of change, but nonetheless I did expect to see that it might, you know, mediate the results in some way, but no, we didn't see that this time.

Nick: It's sort of astonishing that just giving feedback even without motivation could make such an impact on behaviour change and without wanting to get too controversial, you know, this idea that you don't have to delve into people's childhoods or make them commit to something or appeal to a higher power, they're simply giving some accurate knowledge about what people are doing could have an effect.

It also presumably goes against a lot of what some people believe about a sort of a brain disease model of alcohol. Again, I don't want to be too controversial here, but if this was something that you couldn't change, and yet your research is showing that a bit of factual information can lead to significant change, that's astonishing.

Antoinette: Well, I mean, it is, it is really astonishing, at least it's the case for young hazardous drinking. We have to be a little bit circumspect, I suppose. We need to build on these findings to see if this type of personalised feedback has the same impact in the wider community or other cohorts, whether, for example, men in middle age will react in the same way to this type of feedback is yet to be seen, but yeah, that's coming work.

Cassie: But it's also fascinating, a lot of the, the models of behaviour change have motivation as a core kind of feature to dial up or dial down in terms of encouraging a behaviour change.

A fascinating part of your research is how you get accurate feedback to these drinkers, and we probably can all reflect on having less than ideal self-reports when we ask someone, you know, how much did you drink in this session or whatever the behaviour is. So how did you develop ways to assess drinking in a real-time, more accurate way than just asking someone on Monday how much they drank on the weekend?

Antoinette: So during my PhD I designed an app, which was designed to help researchers capture real-time information about drinking.

At the time, I was hoping to develop a tool that would overcome some of the limitations around accurately assessing alcohol use. At that point we were relying on sort of summary retrospective measures of alcohol intake, and this is, as you say, there are disadvantages to that type of assessment. People find it difficult to conceptualise their intake. They're often overlooking high intake sessions, so they're sort of applying an average already to their own drinking.

And obviously there's difficulties with recall, so the information's not particularly accurate and it's certainly not very nuanced. So we reasoned that if we had an app, we could have people recording their drinking as it happened, and we were hoping that it would provide very accurate and detailed information.

The app's called Alcohol Capture, and it enables people to track consumption for a period of days. We typically use 14 days, but it's variable. They get notifications to input data a couple of times a day, but they can also open the app at any time and put information in. And all Australian drink sizes have been programmed into the app, so people are not having to make complicated calculations in their head about standard drink sizes.

And an early paper from my PhD showed that participants were recording greater frequency of drinking on the app and higher intake, as opposed to when completing the retrospective measures. So that's the app we've been using in our feedback studies. We're providing people with this personalised feedback based on data coming from the app in the hope that it's, it's very accurate and it's linked quite clearly to actual drinking episodes. We have simultaneously developed an app to assess cognition in real time, and this is called CheckCog.

It allows us to assess both response inhibition and working memory several times a day again for 14 days, and so if you think about what I said before, we're assessing elements of executive function with this app. And just this week, in fact, a colleague of mine, Dr Gezelle Dali, has found that day to day fluctuations in cognition assessed via this app predicts drinking that day.

So, this is great because this is opening up the door for us to give just in time feedback where we can potentially tell people about their impulsivity in real time on the day, in the hope that it influences drinking later that day.

Cassie: And just on that, I think people wouldn't necessarily be surprised to think that drinking might impact cognition or performance on cognitive tasks, but what you're saying is that it is the other way as well?

So if your cognition is declining, you are then more likely to engage in drinking?

Antoinette: Yeah, yeah, so she's found differences in cognition sort of measured across the two time points in the day, are predicting that drinking on the day, yeah.

Cassie: And what sort of cognitive tasks are these just so people can imagine?

Antoinette: So the response inhibition task is a task called a stop signal task and it requires people to respond quickly to what we call a 'go stimulus', and then every so often there's a 'no go' stimulus. People don't know when it's coming, the task goes very quickly, so they're often partway towards responding as though it's a go stimulus and then they get this little sound to tell them no, no, stop, and it, it's quite difficult to stop in that scenario.

I liken it to being at a traffic light, when you've hit the traffic lights and you see the amber light go on, and you've got to make that split decision between stopping there and then or going through the lights, so the task, it's sort of analogous to that kind of task.

Cassie: But it's just something they're doing on a computer, like just?

Antoinette: Yeah, sorry, in this case it's on the app and yeah, there's little letters come up and you're responding to some and not to the others.

Cassie: And that can predict drinking, that's fascinating.

Antoinette: That's right.

Nick: So just out of interest, compared to your app, how much are people typically underreporting their drinking by retrospective self-report? If you can just give us a rough estimate, are we talking 50%, 20%?

Antoinette: Yeah, well, it was a significant difference. I can't recall off the top of my head exactly what it was. My memory is it was about 2 standard drinks per week difference, so that's not an enormous quantity, but at the same time over time it is.

And you know, nowadays the guidelines are quite strict and they've come down even since I, I did that study, so, you know, 2 drinks in a day, that takes you from potentially at 4 drinks to not binge drinking to 6 drinks to binge drinking.

Nick: So I, I find it fascinating also how you develop these digital interventions that you've been telling us about. So in a recent paper you compared some different formats for delivering the personalised feedback that you give people, and I think you had some formats based on text or images and some that were designed by researchers, and I think one that was co-designed by researchers and users. What did you find?

Antoinette: Yeah, this was also quite surprising. Essentially in our original feedback study, the feedback we were providing participants was very text heavy, it arrived via email and it was about half a page of fairly dense information. And although the study and the intervention was effective, we had thought that if we could involve consumers, we might be able to improve the look and feel of it and maybe in turn even its effectiveness.

So we consulted with a youth advisory board located at the Matilda Centre at the University of Sydney and we developed some prompts to use with focus groups, and then we held a series of focus groups involving young people here in Melbourne. And at the end of this rather convoluted process, we had 3 types of feedback. We had this original text heavy feedback, we had an image-based feedback that we had developed with the youth advisory board, but essentially it was researched and designed.

And then we had the wholly image-based feedback that our focus group participants had, had designed. Now our focus group participants were from about 17 to 25, 26 years of age, and they were from different walks of life in Melbourne.

When we presented the three types of feedback to a new sample of participants, they certainly preferred the focus groups designed feedback. It was pretty, it was colourful, yeah, hands down they preferred that. But then with another group of people, we actually provided the feedback about their drinking and impulsivity in one of these 3 formats, and it didn't impact the reduction in drinking in any way, regardless of what feedback they saw, they all reduced their drinking to the same amount.

So likability is certainly an important point for an intervention. But co-design processes are really time consuming, they're very expensive, and a lot more work clearly needs to be done in this area to determine whether co-design adds sufficient value to the end product and to justify the costs, I think.

Cassie: Yeah, I think it's a really interesting area in, in my field in behaviour change, this difference between an ad or a message that people like, and an ad or a message that is effective are very two different things, and sometimes we put too much weight on the likability and doesn't necessarily impact the effectiveness.

Antoinette: I had wondered actually whether the text-based feedback was effective because it looked so serious, and, and people attended to it, but I mean it, it would seem that it doesn't matter how the feedback comes, it's effective.

Cassie: What, what implications does this work have for just lowering the prevalence and the, and the burden of alcohol use problems? Is it about stopping them before they start to become a problem, or can they also treat long-standing hazardous drinkers? What do you see as the potential for these types of interventions?

Antoinette: Well, I mean, alcohol poses a very significant burden in most regions of the world, that's 5% of all deaths, are attributed to alcohol, that's 3 million deaths a year.

In Australia, it accounts for 4 to 5% of the burden of disease, there's 40 to 4500 people dying each year due to alcohol-related issues and 150,000 hospital admissions, so the burden is enormous, it exceeds $66 billion.

So undoubtedly there's a constellation of factors involved in hazardous alcohol use and the transition to alcohol use disorder. Impulsivity is just one of these factors. It would appear though that if we can have people who are engaging in hazardous drinking, become more aware of their consumption, have them understand that it may be to do with impulsivity and that there are these links between impulsivity and vulnerability to transition, it seems as though um we can reduce their consumption.

And that would go some way to reducing the burden if we can reliably do that, do that, but yeah, as I said, we probably need to extend this work into other cohorts and other groups to really definitively, uh I guess address your question.

Nick: And pardon the pun, but those are very sobering statistics. And I'm serious about that because obviously the cost here is enormous. So we like to finish our episodes with some practical takeaways for our listeners. So let's say they or someone they love or care about is engaging in hazardous drinking. What sort of advice would you give? Does your work offer any guidance about what they could do about it?

Antoinette: Yeah, I think that a first step is to track your own consumption. So it's an easy thing to do, maybe over 14 days, 21 days, record things in a little diary or on your phone, and then have a look at how it compares with national guidelines. People can do this themselves, and it could for some people be enough of a mechanism for them to consider their intake and to reduce consumption.

I would say if people additionally feel that they might be more impulsive, that they have a tendency to make impulsive decisions, or they have a tendency to have difficulties with control, then I would seek help, uh, I would, you know, perhaps have a first conversation with a GP or some other mental health expert, um, and then perhaps look up some of the um numbers that you're going to put in the show notes.

Cassie: But I think it's just fascinating that I think a lot of these problems obviously are multifaceted and lots of things can go into it, but a very simple thing that people can do is just track their consumption and look at that, and that might be enough for some people to make a safe change in their behaviour.

Antoinette: Yeah, our research really suggests that that's the case.

Cassie: Fascinating research, Antoinette, thank you for joining us today on PsychTalks.

Antoinette: Thank you, thank you for having me.

Cassie: That was Dr Antoinette Poulton speaking about her research on impulsivity, alcohol use, and how simple feedback can support behaviour change.

If you'd like to learn more about Antoinette's work, including her current studies and resources, you can find more information in our show notes.

And if you need support on these issues, you can check out Daybreak at hellosundaymorning.org or call the National Alcohol and Other Drug Hotline at 1800-250-015.

PsychTalks is produced by Mairead Murray, Gemma Papprill and Celia Harvey, with audio engineering by Phil Shaw. It is a production of the University of Melbourne, Australia. Thanks for listening. If you enjoyed this episode, please follow, subscribe or share it with a friend. See you next time.