BETs: a spreading plague with lethal consequences

BETS: uma praga que se alastra e mata

BETs: una plaga en expansión con consecuencias letales

1. César Augusto Trinta Weber

Affiliation of authors:

1 MD. PhD. Faculdade de Medicina, Universidade Luterana do Brazil, Canoas, RS, Brazil. Hospital Universitário de Canoas, Canoas, RS, Brazil. Secretaria Estadual da Saúde do Rio Grande do Sul, Porto Alegre, RS, Brazil.

2 Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil. Faculdade de Medicina, Universidade do Porto, Porto, Portugal. Programa de Pós-Graduação em Medicina Molecular, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.

Chief Editor responsible for the article: Leandro Fernandes Malloy-Diniz

Authors contributions according to the Taxonomia CRediT: WeberCAT, Silva AG [1,12,13,14]

Disclosure of potential conflicts of interest: none

Funding: none

Approval Research Ethics Committee (REC): not applicable

Received on: 2025/08/07 | Accepted on: 2025/08/08 | Published on: 2025/08/13

How to cite: Weber CAT, da Silva AG. BETs: a spreading plague with lethal consequences. Debates Psiquiatr. 2025;15:1-16. https://doi.org/10.25118/2763-9037.2025.v15.1496

Abstract

Online sports betting, commonly referred to as "BETs," has rapidly evolved into a public health issue in Brazil. Enabled by widespread access to smartphones and instant payment systems such as Pix, betting has become available anytime and anywhere. The illusion of opportunity and entertainment conceals an emerging mental health crisis, particularly among youth. Gambling disorder is recognized in the DSM-5 as an addictive disorder, sharing neurobiological mechanisms with substance dependence. The Brazilian context presents a particularly concerning scenario: weak regulation, aggressive marketing by betting platforms, and insufficient preparedness of public health services. As young people face financial hardship, depression, social isolation, and even suicidal ideation, the implementation of preventive and therapeutic responses becomes urgent. Drawing on neurobiological evidence related to the brain's reward circuitry and on international experiences, this narrative review advocates for integrated regulatory, educational, and healthcare policies to address online betting as a significant social determinant of health.

Keywords: online gambling, public health, behavioral addiction, adolescent health, Brazil, regulation.

Resumo

As apostas esportivas online, conhecidas como “BETs”, evoluíram rapidamente para um problema de saúde pública no Brasil. Facilitadas pelo amplo acesso a smartphones e a sistemas de pagamento instantâneo como o Pix, as apostas tornaram-se acessíveis a qualquer hora e em qualquer lugar. A ilusão de oportunidade e entretenimento mascara uma crise emergente de saúde mental, particularmente entre os jovens. O transtorno do jogo é reconhecido pelo DSM-5 como um transtorno aditivo, com mecanismos neurobiológicos semelhantes aos da dependência química. O contexto brasileiro configura um cenário particularmente preocupante: regulamentação frágil, marketing agressivo por parte das plataformas de apostas e preparo insuficiente dos serviços públicos de saúde. À medida que jovens enfrentam dificuldades financeiras, depressão, isolamento social e até ideação suicida, torna-se urgente implementar respostas preventivas e terapêuticas. Com base em evidências neurobiológicas relacionadas ao circuito de recompensa cerebral e em experiências internacionais, esta revisão narrativa defende políticas regulatórias, educacionais e assistenciais integradas para enfrentar as apostas online como um determinante significativo da saúde.

Palavras-chave: jogo online, saúde pública, adição comportamental, saúde do adolescente, Brasil, regulação.

Resumen

Las apuestas deportivas en línea, conocidas como "BETs", han evolucionado rápidamente hasta convertirse en un problema de salud pública en Brasil. Facilitadas por el amplio acceso a teléfonos inteligentes y a sistemas de pago instantáneo como el Pix, las apuestas se han vuelto accesibles en cualquier momento y lugar. La ilusión de oportunidad y entretenimiento oculta una crisis emergente de salud mental, especialmente entre los jóvenes. El trastorno por juego está reconocido por el DSM-5 como un trastorno adictivo, con mecanismos neurobiológicos similares a los de la dependencia a sustancias. El contexto brasileño configura un escenario particularmente preocupante: regulación débil, marketing agresivo por parte de las plataformas de apuestas y preparación insuficiente de los servicios públicos de salud. A medida que los jóvenes enfrentan dificultades económicas, depresión, aislamiento social e incluso ideación suicida, se vuelve urgente implementar respuestas preventivas y terapéuticas. Basado en evidencia neurobiológica relacionada con el circuito de recompensa cerebral y en experiencias internacionales, este revisión narrativa aboga por políticas integradas de regulación, educación y atención sanitaria para abordar las apuestas en línea como un determinante significativo de la salud.

Palabras clave: juego en línea, salud pública, adicción conductual, salud del adolescente, Brasil, regulación.

Introduction

Online sports betting has quickly become a significantly expanding phenomenon in Brazil. Due to the widespread use of smartphones and the ease of instant payment systems like Pix, individuals can now place bets simply and swiftly, virtually anywhere and at any time.

What previously required a physical visit to a traditional betting house is now available in the palm of one’s hand, disguised as a form of seemingly harmless entertainment accessible to all. However, the rapid growth of this form of gambling entails substantial risks to collective mental health, with particularly concerning impacts among adolescents and young adults .

Although online sports betting is expanding similarly in other Latin American countries, this study focuses exclusively on the Brazilian context, given its specific market dynamics and unique social and regulatory conditions.

In Brazil, the sharp increase in this practice has been fueled by a confluence of factors: easy access to digital technologies, intense exposure through digital media, and the lack of adequate regulatory oversight. Combined, these elements have fostered an environment in which betting is rapidly disseminated—often without the necessary consumer protections.

For comparative purposes, it is important to highlight that countries such as Mexico, Colombia, Peru, and Chile have engaged in more robust legislative debates focused on advertising, protection of minors, and sector taxation. This indicates that online sports betting is a regional issue, even though the analysis and proposals herein are rooted in the Brazilian reality and aim to contribute to national discussions .

Objective

To analyze online sports betting as an emerging public health challenge in Brazil.

Method

This is a narrative review with an applied scope, developed to assess the impacts of online sports betting within the context of Brazilian public health. The review was conducted from January to June 2025, following methodological guidelines for narrative reviews with thematic breadth and argumentative rigor.

The search strategy included the databases PubMed, Scopus, Google Scholar, and SciELO, as well as official public documents and technical-scientific reports. The following descriptors were used in Boolean combinations: “sports betting,” “gambling disorder,” “public health,” “technology adoption,” “regulation,” “adolescents,” and “addictive behavior.” The time frame ranged from 2013 to 2025, prioritizing publications following the emergence of smartphones and the early regulation of fixed-odds betting in Brazil.

Inclusion criteria: Peer-reviewed articles addressing online sports betting and mental health; clinical and epidemiological studies; systematic reviews; institutional and regulatory documents applicable to the Brazilian or comparable international context; evidence regarding public policies, addiction neuroscience, and gambling regulation.

Exclusion criteria: Studies exclusively focused on in-person gambling; opinion-based publications lacking empirical evidence.

Data analysis involved critical reading and narrative synthesis of the evidence, with emphasis on intersections among mental health, digital behavior, regulatory policy, and psychosocial impact.

Frame 1 presents the methodological strategy used for the search and selection of articles included in this narrative review.

Results and Discussion

In 2023, the Brazilian betting market moved over R$100 billion. This growth has been driven by advertising campaigns involving celebrities and influencers, often targeting young audiences .

Di Censo et al. examined the influence of sports betting marketing on youth behavior, demonstrating that advertising strategies contribute directly to the normalization of gambling and increased betting intentions. These ads frequently associate betting with masculinity, status, and excitement, having a more significant impact on young men. Continuous exposure to such marketing is strongly correlated with more frequent betting and higher risk of developing gambling-related problems, highlighting the urgent need for stricter advertising regulations targeting youth.

The promise of quick financial gain is particularly seductive for individuals aged 15 to 30, a demographic more vulnerable to digital compulsions . Shaygan et al. investigated the mental health impacts of problematic sports betting in young adults and found significant associations with elevated symptoms of depression, anxiety, and stress. Additionally, those with problematic betting patterns reported increased alcohol and substance use, and lower subjective well-being and quality of life. The findings reinforce that frequent involvement in sports betting is not merely recreational, it is a significant risk factor for psychosocial harm among youth, calling for preventive and clinical interventions.

Gambling disorder was initially classified in the DSM-III as an impulse control disorder and was later reclassified in the DSM-5 as an addictive disorder based on new neurobiological evidence . This reclassification acknowledges that betting behavior activates the same brain reward circuits implicated in substance dependence—particularly via dopamine release during intermittent wins and “near-miss” situations .

Digital platforms exploit these vulnerabilities using advanced technology. Their algorithms personalize user experiences with stimuli that reinforce compulsive behavior, such as visual effects, bonus notifications, rapid reward cycles, and social competition elements—activating regions like the nucleus accumbens . These stimuli have a greater impact on adolescents, whose prefrontal cortex is still developing, impairing judgment and increasing impulsivity.

Valenciando-Mendoza et al. conducted a systematic review identifying strong clinical correlations in sports bettors, highlighting high prevalence of psychiatric comorbidities—especially anxiety, depression, and substance misuse. Sports bettors frequently present with high impulsivity, inhibitory control deficits, and cognitive distortions such as the illusion of control. These clinical markers suggest that sports betting behavior is embedded in a broader framework of psychological dysfunctions and requires tailored therapeutic approaches.

Barrera-Algarín et al. analyzed the rise of online sports betting and the emergence of a new profile of gamblers with gambling disorder. Their findings show that due to widespread access to digital platforms, instant gratification, and intense marketing exposure, young users tend to begin betting earlier and develop risky behaviors faster. The study underscores impulsivity and frequent technology use as key factors in this profile, stressing the need for prevention strategies that address the digital context enabling problematic gambling.

International data illustrates the extent of potential harm. A Danish study involving 1,381 individuals diagnosed with gambling disorder revealed high rates of psychiatric comorbidities (e.g., depression in 39.8%), criminal behavior, and elevated healthcare system costs . In the UK, 42% of individuals aged 18 to 24 gambled online in 2023 . A longitudinal study (2018–2020) demonstrated an association between gambling disorder severity and suicide attempts, underscoring the need for early intervention . A recent meta-analysis estimated a prevalence of 31.6% for suicidal ideation and 13.2% for suicide attempts among individuals with gambling disorder—more than double the general population’s risk .

Countries such as the UK have incorporated gambling into clinical guidelines. The NICE recommends that physicians routinely ask patients about gambling habits for early identification and support . The Lancet Commission on Public Health recognizes gambling as a global public health priority . Australia has adopted daily betting limits, mandatory warning messages, and advertising restrictions during family programming .

In Brazil, while comprehensive population data is lacking, studies and reports suggest rising debt, school dropout, and suicidal ideation among young people. A national survey in 2024 found that 44% of bettors lose more than they win, regardless of sex, age, or region . The third edition of the Brazilian National Alcohol and Drugs Survey (LENAD III) showed that 14% of adolescents have gambled in their lifetime and 10.5% in the past year .

The enactment of Law No. 14,790/2023 represented a significant milestone by regulating fixed-odds betting in Brazil, establishing requirements such as licensing, taxation, and integrity measures. However, its implementation remains incipient and uneven, with persistent regulatory gaps in areas such as youth-targeted advertising, spending limits, and protections for vulnerable users .

The global review by Killick and Griffiths provided a comprehensive overview of sports betting in diverse legal and cultural contexts, confirming rapid growth in countries with permissive regulation. While prevalence rates vary regionally, the most recurrent pattern involves young males who bear the brunt of financial, social, and psychological harm. The study concludes that sports betting constitutes a global public health problem and supports regulatory policies, educational campaigns, and expanded therapeutic services as essential response measures.

The lack of clear regulation on digital marketing practices and weak enforcement limit the immediate impact of existing laws. Thus, while Law No. 14,790/2023 marks an important institutional advance, it requires more robust and public health-oriented regulatory developments to effectively mitigate the psychosocial risks associated with fixed-odds betting .

Moreover, Brazil’s public healthcare system (SUS) is not yet structured to meet this emerging demand. Few Psychosocial Care Centers for Alcohol and Drugs (CAPS-AD) have specific protocols, and professionals receive limited training on gambling disorder .

Accordingly, the adoption of regulatory guidelines, as outlined in Frame 2, is proposed to mitigate risks and enhance population protection.

It is important to emphasize that the goal is not to prohibit gambling per se, but rather to mitigate the harms of the current digital model, which presents structural asymmetries between vulnerable users and highly profitable platforms. The system is designed to promote repeated losses, sustaining the operators’ profit margins. The recognition of online betting as a social determinant of health should guide the development of evidence-based policies. On one hand, the expansion of the Brazilian Unified Health System’s (SUS) response, the training of professionals, the inclusion of the topic in school curricula, and effective sector regulation are urgent measures. On the other hand, coordinated efforts between Brazilian states and municipalities could strengthen regulatory frameworks and support the production of more robust epidemiological data—essential for addressing the issue effectively and with social justice.

In addition to the guidelines proposed in this review, the third edition of the Brazilian National Alcohol and Drugs Survey (LENAD III) presented a set of strategic recommendations aimed at mitigating the harms associated with online sports betting . These recommendations underscore the need for an intersectoral approach, combining regulation, protection, health education, and public policy financing. They are organized into four main action areas, as summarized in Frame 3.

These recommendations expand upon the previously discussed guidelines by offering a framework more closely aligned with epidemiological evidence and the intersectoral responsibilities of the State—serving as a foundation for the development of effective public policies to address the impacts of BETs, particularly among youth and vulnerable populations.

As additional reinforcement, the Brazilian Federal Court of Accounts (Tribunal de Contas da União, TCU) published, in 2025, Ruling No. 1173/2025 - TCU - Plenary, which synthesizes and translates the main findings of an audit conducted on the public health impacts of fixed-odds betting (“BETs”) in Brazil. The document highlights that, since the enactment of Law No. 13.756/2018 and its update through Law No. 14.790/2023, the betting sector has grown exponentially, with an estimated transaction volume reaching R$ 130 billion in 2024. The TCU emphasizes that this unregulated growth has led to significant financial strain for many families, including recipients of the Bolsa Família Program, and has contributed to increased household indebtedness and family breakdown. These findings corroborate data presented in this review, originating from both academic and institutional sources, by identifying sports betting as an aggravating factor in social vulnerabilities and psychosocial risk .

In addition, the TCU identified critical shortcomings in the Ministry of Health’s response, including the absence of specific indicators for monitoring gambling disorder, limited public awareness campaigns, weak intersectoral coordination, and insufficient capacity within the Psychosocial Care Network (RAPS) to manage cases effectively. A survey cited by the court revealed that over half (55.2%) of professionals within the Unified Health System (SUS) reported feeling unprepared to treat patients with gambling-related disorders. The ruling also criticized the inefficacy of protective measures directed at children, adolescents, and individuals already diagnosed with gambling addiction, and noted that state efforts are vastly outweighed by the powerful marketing strategies employed by betting operators. In summary, the ruling concludes that governmental actions lack coordination and effectiveness, and it urgently recommends strengthening the national plan to address gambling disorder, including measures for prevention, early detection, professional training, and structural enhancement of the care network .

Study Limitations

Despite the relevance of the topic and the theoretical depth of the analysis, this investigation has limitations. First, there is a lack of systematic and updated national population data on the prevalence and impact of online sports betting, hindering precise epidemiological assessments. Much of the evidence cited is drawn from international studies or recent institutional surveys with limited coverage.

Similarly, findings on mental disorders associated with gambling are partially based on clinical inferences and observational reports, limiting generalizability.

Another limitation is the absence of national longitudinal studies correlating betting platform usage with psychiatric outcomes.

Lastly, the rapid pace of technological and legislative changes may quickly render parts of this analysis outdated, reinforcing the need for continuous monitoring and regular policy and literature updates.

Conclusions

This review is grounded in well-established international scientific literature, emerging national data, and conceptual frameworks from the neuroscience of addictive behavior. However, the lack of longitudinal studies and comprehensive epidemiological surveys in Brazil underscores the exploratory and propositional nature of this work.

Tackling online sports betting requires coordinated responses based on scientific evidence and supported by effective public policies. Given the growing involvement of youth in high-risk activities, regulatory fragility, and rising psychosocial impact, strengthening surveillance, healthcare, and prevention systems is imperative.

Integrating sector regulation, healthcare professional training, and educational campaigns is essential to mitigating associated harms. Intersectoral policies can expand preventive action and enhance protection for vulnerable populations.

Finally, greater recognition of gambling disorder as a public health issue could enable earlier interventions, reduce social costs, and significantly improve protection for at-risk individuals. This represents a crucial step in Brazil’s progress toward an effective and sustainable response to this emerging challenge.