Concerns about problematic gaming behaviors deserve our full attention. However, we claim that it is far from clear that these problems can or should be attributed to a new disorder. The empirical basis for a Gaming Disorder proposal, such as in the new ICD-11, suffers from fundamental issues. Our main concerns are the low quality of the research base, the fact that the current operationalization leans too heavily on substance use and gambling criteria, and the lack of consensus on symptomatology and assessment of problematic gaming. The act of formalizing this disorder, even as a proposal, has negative medical, scientific, public-health, societal, and human rights fallout that should be considered. Of particular concern are moral panics around the harm of video gaming. They might result in premature application of diagnosis in the medical community and the treatment of abundant false-positive cases, especially for children and adolescents. Second, research will be locked into a confirmatory approach, rather than an exploration of the boundaries of normal versus pathological. Third, the healthy majority of gamers will be affected negatively. We expect that the premature inclusion of Gaming Disorder as a diagnosis in ICD-11 will cause significant stigma to the millions of children who play video games as a part of a normal, healthy life. At this point, suggesting formal diagnoses and categories is premature: the ICD-11 proposal for Gaming Disorder should be removed to avoid a waste of public health resources as well as to avoid causing harm to healthy video gamers around the world.

We greatly appreciate the care and thought that is evident in the 10 commentaries that discuss our debate paper, the majority of which argued in favor of a formalized ICD-11 gaming disorder. We agree that there are some people whose play of video games is related to life problems. We believe that understanding this population and the nature and severity of the problems they experience should be a focus area for future research. However, moving from research construct to formal disorder requires a much stronger evidence base than we currently have. The burden of evidence and the clinical utility should be extremely high, because there is a genuine risk of abuse of diagnoses. We provide suggestions about the level of evidence that might be required: transparent and preregistered studies, a better demarcation of the subject area that includes a rationale for focusing on gaming particularly versus a more general behavioral addictions concept, the exploration of non-addiction approaches, and the unbiased exploration of clinical approaches that treat potentially underlying issues, such as depressive mood or social anxiety first. We acknowledge there could be benefits to formalizing gaming disorder, many of which were highlighted by colleagues in their commentaries, but we think they do not yet outweigh the wider societal and public health risks involved. Given the gravity of diagnostic classification and its wider societal impact, we urge our colleagues at the WHO to err on the side of caution for now and postpone the formalization.

With proposals to include “gaming disorder” in both the Diagnostic and Statistical Manual (DSM) and International Compendium of Diseases (ICD), the concept of video game addiction has gained traction. However, many aspects of this concept remain controversial. At present, little clarity has been achieved regarding diagnostic criteria and appropriate symptoms. It is unclear if symptoms that involve problematic video gaming behavior should be reified as a new disorder, or are the expression of underlying mental conditions. Nonetheless, the recent proposals around gaming disorder from respected bodies such as the World Health Organization and the American Psychiatric Association seem to lock much of the applied research into a confirmatory trajectory. Since the DSM–5 proposal, research is increasingly focused on the application of the proposed criteria, as opposed to broadly testing validity and necessity of the overarching construct. This raises multiple concerns. First, the current approaches to understanding “gaming addiction” are rooted in substance abuse research and approaches do not necessarily translate to media consumption. Second, some research has indicated that “video game addiction” is not a stable construct and clinical impairment might be low. Third, pathologizing gaming behavior has fallout beyond the therapeutic setting. In light of continuing controversies, it is argued that the currently proposed categories of video game addiction disorders are premature.

In this paper we investigate the phenomenon colloquially known as “loot boxes”. Loot boxes became a hot topic towards the end of 2017 when several legislative bodies proposed that they were essentially gambling mechanisms and should therefore be legislated as such. We argue that the term “loot box” and the phenomena it covers are not sufficiently precise for academic use, and instead introduce the notion of “random reward mechanisms” (RRMs). We offer a categorization of RRMs, which distinguishes between RRMs that are either “isolated” from real-world economies or “embedded” in them. This distinction will be useful in discussions about loot boxes in general, but specifically when it comes to the question of whether or not they represent instances of gambling. We argue that all classes of RRMs have gambling-like features, and may be problematic in different ways, but that only one class can be considered to be genuine gambling.

Purpose of Review Loot boxes are gambling-like monetisation mechanics in video games that are purchased for opportunities to obtain randomised in-game rewards. Gambling regulation is increasingly being informed by insights from public health. Despite conceptual similarities between loot boxes and gambling, there is much less international consensus on loot box regulation. Various approaches to regulating loot boxes are reviewed via a public health framework that highlights various trade-offs between individual liberties and harm prevention. Recent Findings Many countries have considered regulation, but as yet only a few countries have taken tangible actions. Existing regulatory approaches vary greatly. More restrictively, Belgium has effectively ‘banned’ paid loot boxes and prohibits their sale to both children and adults. In contrast, more liberally, China only requires disclosure of the probabilities of obtaining potential rewards to provide transparency and perhaps help players to make more informed purchasing decisions. Most other countries (e.g., the UK) have adopted a ‘wait-and-watch’ approach by neither regulating loot box sales nor providing any dedicated consumer protection response. Industry self-regulation has also been adopted, although this appears to elicit lower rates of compliance than comparable national legal regulation. Summary Many potential public health approaches to loot box regulation, such as expenditure limits or harm-reducing modifications to loot box design (e.g., fairer reward structures), deserve further attention. The compliance and clinical benefits of existing interventions (including varying degrees of regulation, as adopted by different countries, and industry self-regulation) should be further assessed. The current international variation in loot box regulation presents opportunities to compare the merits of different approaches over time.