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The Untapped Potential of the Gaming Community: Narrative Review

The Untapped Potential of the Gaming Community: Narrative Review Background: Video gamers are a population at heightened risk of developing obesity due to the sedentary nature of gaming, increased energy intake, and the disruption caused to their sleep. This increases their risk of developing a number of noncommunicable diseases. To date, research seeking to improve health behaviors has focused on developing novel video games to promote behavior change. Although positive results have emerged from this research, large-scale success has been limited due to the lack of transferability to mainstream games and the focus on children and adolescents. The gaming community has a number of unique aspects, which have received comparatively less attention than the development of new video games. Objective: The purpose of this paper is to highlight under-researched areas that have the potential to encourage positive health behavior among this community. Methods: A narrative review of the lay and academic literature was conducted to provide context and support to our claims that further research could be beneficial in this area. Results: Research has found that advertising can have implicit effects on an individual’s memories, which could influence later decisions. However, the effect of the exponential growth of in-game advertisements and the brand sponsorship of gaming events and professional gamers have not been explored in the gaming community. The possibility of using advertising techniques to encourage positive health behaviors within games or at these events has also not been explored. Research suggests that virtual communities can be effective at disseminating health information, but the efficacy of this needs to be explored using known community influencers within the gaming community. Conclusions: This paper has highlighted a number of potential avenues for the development of interventions within the gaming community. Further research must be conducted alongside game developers to ensure that any in-game developed interventions do not deter gameplay and gamers to ensure that potential approaches are acceptable. (JMIR Serious Games 2018;6(3):e10161) doi: 10.2196/10161 KEYWORDS video games; advertisements; health behavior http://games.jmir.org/2018/3/e10161/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10161 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Goodman et al and awareness of health behaviors or by including physical Introduction activity within the game itself. A large body of research has explored the potential to develop games to improve health Background [25-27]. A recent review of systematic reviews found that active Obesity has become a major problem, with an estimated 1.9 video games among children could increase levels of physical billion adults worldwide classed as overweight or obese in 2014 activity and energy expenditure. Health education games also [1]. Furthermore, the growing prevalence of childhood obesity have the potential to support diabetes-related behavior and is now described by the World Health Organization as a major dietary change [28]. However, research in this area has focused challenge of the 21st century [2]. Obesity is linked to an on children and adolescents, whereas the average gamer age is increased risk of developing a number of noncommunicable 35 years in the United States [29]. Furthermore, it is unlikely diseases [3] and is the second largest cause of cancer after that long-standing gamers will be motivated to change their smoking [4]. Previous research suggests those with a higher gaming habits from mainstream video games to active or body mass index are at an increased risk of up to 17 different educational video games. Therefore, additional opportunities cancers [5-7]. An increased intake of energy-dense foods and for interventions targeting gamers should be explored. increasingly sedentary lifestyles are central to the rise in obesity Objective prevalence [1]. The video gamer population is at an increased risk of developing obesity because traditional gaming has now This paper aims to discuss the potential avenues for future become a sedentary behavior. research in this area, drawing on the attributes that are unique to the gaming community. Sedentary behavior is also implicated as an independent risk factor for a number of noncommunicable diseases [3]. Methods Epidemiological studies have found that sedentary behavior is a strong risk factor for the development of endometrial [8,9], This paper comprises a narrative literature review. It draws on breast [10,11], and ovarian [12] cancer in women. In men, lay literature to provide context and descriptive detail and sedentary behavior is a strong risk factor for the development academic literature to support the claims that further research of colorectal (borderline impact for women) [13] and prostate could be beneficial in developing this area for health behavior [14] cancer. Sedentary behavior involves performing activities change. This literature was identified through the following in a sitting or lying position while using low levels of energy, electronic databases: Web of Science, MEDLINE, Google, and and it is considered separate and distinct from a lack of physical Google Scholar. The following keywords were used in various activity [15]. Sedentary behavior includes leisure, work, and combinations: “video games,” “gamers,” “professional gamers,” transportation activities, and it is commonly measured by “gaming events,” “advertising,” “in-game advertisement,” quantifying television viewing, video game use, or general “vloggers,” “forums,” “online communities,” “virtual screen time [16,17]. Research suggests that sedentary behavior communities,” “fast food,” and “marketing.” A snowball method increases the risk of developing obesity [18-20], with those who was also employed, wherein references from relevant papers watch television for more than 20 hours a week more likely to were reviewed to identify other relevant papers. be affected by obesity compared with those who only watch television for 5 hours or less (25% and 14%). Estimates are This review will refer to both hardcore and casual gamers as similar for the use of computers [21]. gamers due to the lack of a universally accepted definition to objectively categorize these 2 groups [30] and the general lack Video games have also been found to increase energy intake of distinction between the 2 groups in research to date. The term among healthy males. A randomized crossover study found that gaming community will be used to cover the areas in which despite increased levels of energy expenditure while playing gamers interact, such as video games, gaming events, online video games (mean energy increase compared with the rest forums, and video blogs. Gamers are extremely heterogeneous, state=89 kJ), this was counteracted by higher levels of energy representing a range of demographic, social, and behavioral intake after playing video games, resulting in an energy surplus groups, and they span international and cultural divides. of 335 kJ compared with those who rested for the same period Understanding the heterogeneity of gamers and their behaviors [22]. Furthermore, video games have been implicated in the and influences and subsequently targeting interventions or disruption of sleep when played before bedtime. Research marketing would provide a rich avenue of research to pursue; involving healthy, good-sleeping adolescents (N=21) found that however, this aspect is not explored in this review. there was a highly significant negative correlation between gaming time and sleep duration (r=−.92) [23]. Shorter sleep Results duration has been associated with an increased risk of weight gain among males, and a higher incidence of obesity was Several aspects of gaming that could be utilized to engage observed in males with shorter sleep duration [24]. Those who gamers in health behavior change, including gaming play a large number of video games may, therefore, represent environments, virtual communities, and community influencers, an at-risk population that could benefit from targeted were identified. These features and their ability to be applied interventions. to health behavior change are described and discussed below. The majority of previous research involving gamers has focused solely on the potential for video games to be used as a medium for health behavior change, either by increasing the knowledge http://games.jmir.org/2018/3/e10161/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10161 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Goodman et al to add menu items that appeal to the 18- to 34-year-old In-Game Advertisement demographic and expand late-night sales” [49]. Dynamic IGAs, Companies use marketing to connect consumers with their such as those used by Wendy’s, can cost around US $4-12 per products and services [31]. There is a range of marketing 1000 impressions received (1 impression=the advertisement strategies and tools that companies can employ to promote their being on screen for 10 seconds). Static IGAs that cannot be brand, with advertising being one of the more expensive changed once the game has been released can cost between US approaches. In in-game advertisement (IGA), companies pay $50,000 and $500,000 [50]. to have their brand promoted within a game itself [32,33]. In 2004, companies spent US $34 million on IGA [34]; this Banning HFSS advertisements in games may be more difficult spending grew exponentially to US $3.1 billion in 2011 and than with television or the internet, as such a ban cannot be was expected to reach US $7.2 billion in 2016 [35]. This can targeted at a certain age bracket and a blanket ban approach occur in different forms such as posters or billboards within the may be considered heavy-handed. This ban may also not be game environment, food that is consumed by a character, or possible in certain countries that have laws guaranteeing having a character dressed in branded clothing [36]. However, freedom of speech, such as the United States. However, it may not all games lend themselves to IGA, and it is often only be possible for video games to be utilized in a different way to included if it is seen as congruent with the game. With the rise combat IGA of HFSS. If funds were available, charities (eg, of mobile gaming, advertisements have also started appearing Cancer Research UK or Diabetes UK) could consider in apps at the top or bottom of the phone screen or as short video counteradvertising and place their own IGA’s, which could clips between levels [37]. These advertisements can be target people directly with health-promoting messages or personalized to the user through the use of metadata collected information. Within a collaborative context where charities and by search engines, social media companies [38], and mobile game developers share values on an approach, content of such apps [39], which is thought to make them more effective at premium games could be developed or adverts may be targeted reaching their target audience [40,41]. toward health behavior change to influence implicit memory in gamers. This could be a viable alternative when regulation is Research has found that IGAs have a strong effect on our not an option. Research has shown that gamers develop negative implicit memory. For example, 1 study found that participants attitudes to advertisements that are intrusive and incongruent who played a Formula 1 video game scored significantly higher with the game, as it reduces their sense of realism [51,52]. There on a word-fragmentation task of brand names (that were shown is, therefore, a need for developers willing to take up the in the video game) than those in a control condition [42]. The challenge to show how positive advertisements may be authors concluded that these effects on implicit memory could effectively included in games to support healthy behaviors and in turn influence later decisions. Research has shown this to be choices. the case for television advertising; for example, studies have shown that television advertising for unhealthy food increases Further Promotional Techniques positive attitudes toward junk food in children [43] and increases Brands have diversified their promotional mix beyond food consumption and time spent eating food among adults advertisements to target the gamers in other unique ways. Viral [44]. Interestingly, these studies also found that advertising marketing techniques utilize the internet and already established nutritious food showed an increase in positive attitudes toward social networking services and sometimes community healthy food and less consumption of food in general. influencers to popularize a brand [53]. Burger King teamed up In 2007, Ofcom, the communications regulator for the United with Sony Spain to offer the delivery of fast food to gamers who Kingdom, introduced a ban on television advertisements of high signed up to play with professional gamers online. After fat, salt, or sugar (HFSS) food or drink products for children’s completing a game, the professional gamer would then take the airtime to reduce the exposure of children aged less than 16 order and it would be delivered to the gamer’s door [54]. Viral years to unhealthy foods [45]. The effectiveness of this ban marketing campaigns have been found to be effective tools for provided an estimated reduction in children’s exposure to HFSS the promotion of a brand [53]. Brands have attempted tie-ins advertisements by 37% in 2009 compared with 2005 [46]. with newly released games by offering discounts and prizes to However, with a migration of viewing habits to Web-based people that buy their products. For example, with the release providers, children could still be exposed to HFSS advertising. of the Call of Duty: Black Ops III, gaming prizes including In 2016, a ruling by the UK advertising regulator extended these Double XP could be won by buying special Mountain Dew and restrictions to all nonbroadcast media for children aged less Doritos products [55]. Research has found that the use of than 16 years or that have an audience made up of 25% of promotions for well-known brands can have a positive impact children aged less than 16 years [47]. Although a piece of on its long-term sales prospects [56]. The use of viral marketing legislation was expected to come forward in 2017 to address and promotions by companies seeking to market their brands this, video games were still not covered, and therefore, cannot be stopped; however, their association with large individuals were still exposed to IGA. For example, Wendy’s companies such as Sony can be targeted. In recent years, (a burger chain operating primarily in North America) is set to corporate social responsibility has become increasingly have an IGA for their Baconactor (a 950-calorie burger) on important to both the consumer and the company [57]. It can billboards, bus shelters, and television screens within the virtual affect the way that consumers evaluate a brand and can act as gaming systems of multiple games spanning Xbox, PlayStation protection for a company in times of crisis [58,59]. Therefore, 4, and personal computer platforms [48]. Information on the the encouragement of collaborative work between health product claims, “The addition of the product was part of a push http://games.jmir.org/2018/3/e10161/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10161 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Goodman et al researchers, charities, and corporations would help to serve both the gamer as an advertisement [67]. Celebrities have been found sides. to be effective mediums for advertisements of energy-dense and nutrient-poor food products, both for children [68] and Gaming Events adults [69]. This effect is thought to be due to celebrities Gaming events where gamers and developers gather to play, conferring an implicit benefit and by establishing positive demonstrate, and discuss games are an extension of the gaming associations with the brand through the transference of qualities community. They offer additional opportunities for promoting of physical appeal and likeability from themselves to the product health messages and engagement with audiences. A number of [70,71]. Again, the absolute removal of this incentive and these events attract the video game community, such as comic investment involved for professional gamers might not be book conventions, gaming festivals, and eSports tournaments. achieved easily, as they are often reliant on sponsorship to These typically feature high numbers of sponsors and support their career [72]. Nonetheless, attempting to harness promotions for energy drinks, fast food, and other high-calorie this influence within the community may help to counterbalance foods [60]. unhealthy advertisements. For example, attempting to use the gamers’ influence to create positive attitudes to health behaviors eSports are video gaming competitions involving mostly may be a viable option. professional gamers that contend for prize money. These events are frequently broadcast on television and streamed live over Game-related video bloggers (vloggers) have become the internet. The final for the League of Legends (a multiplayer increasingly popular among gamers. These vloggers post videos online battle arena video game) 2015 World Championship of themselves playing games and giving commentary, glitches drew a global audience of 36 million viewers [61], which was within games, reviews of games, formal walkthroughs of games, greater than the 2016 NBA final that drew 31.2 million viewers using video games to create films from the content, and speed [62]. eSports events have a range of brands that are marketing runs of people completing things in the fastest time [73]. An partners and sponsor both the events and teams. This is a further individual known as PewDiePie is the most popular vlogger on promotional technique to increase brand recognition and YouTube with over 54 million subscribers to his channel and generate positive publicity within the gaming community. The was the first YouTube star to reach over 10 billion views; his energy drink Red Bull, in particular, has a strong brand presence popularity came from his commentary of video games [73,74]. in eSports by sponsoring some of the biggest tournaments, PewDiePie’s popularity offers significant influence with an teams, and clubs [63]. Monster Energy drink, along with Papa engaged audience, with reports of increased game sales when John’s Pizza, sponsors the most successful video gaming team a positive video is posted of the game on his channel [75]. This in the world, Evil Geniuses [64]. This suggests that these events influence has been found to extend to charity give advertisers a unique ability to target and engage gamers. fundraising—raising almost $500,000 for Water Campaign by Although removing brand investment from these events may encouraging subscribers to donate [76], demonstrating the be difficult, as with IGA, it may be of significant value to potential of these influencers to encourage positive behaviors explore promoting advertisements with positive nutrition outside of gaming. messages or conducting health and health behavior seminars in The effect of this influence among online communities is borne the downtime between eSports matches to balance out the effects out in research, which suggests that these influencers provide of other advertisers. In addition, the development of guidelines an important role in the social discourse: encouraging discussion or regulations for food choice management during these events and interaction between members, arranging events, and keeping could encourage organizers to expand the range of food and site content up-to-date [77]. Zhang and Dong [78] have drink choices on offer. Providing incentives, vouchers, or tokens suggested that these influencers can have a lot of sway over the to eat healthier foods (which could be funded through opinions of community members but that this is dependent on ticket-pricing adjustments) could also help modify choice, their ability to engage the community through sociability and moving to a distinct nudge toward healthy eating among this the extent of their knowledge and innovation. Therefore, much community [65]. Initial work might explore the appetite for as with professional gamers, utilizing these community health marketing at these events and the methods to quantify influencers could help to shape opinions on healthy behavior the potential effects for the video game community. among gamers. Community Influencers Virtual Communities Among many communities, there are those who are considered The aforementioned online social communities have developed influencers—individuals who have a greater amount of influence in conjunction with many video games [79]. Individuals use over members’ commitment [66]. Professional gamers have these communities to discuss the game and share ideas and goals emerged as influencers within the gaming community by without the constraints of geographical location [80]. The most becoming the best gamers within their respective gaming genres, frequent gamers, who tend to play multiplayer and online games, and they appear to be styled as celebrities of the gaming can play with other gamers online for an average of 6.5 hours community [60]. These professional gamers receive investment a week and in person for 4.6 hours a week [81], suggesting that from companies and in turn wear clothes with the company’s the social aspect of gaming plays an important role for those logos for matches, in the same way as active sports such as engaged in these communities. Virtual communities have been soccer or tennis. They make videos promoting products and found to be effective mediums to disseminate health information. play video games that are live-streamed on the company’s They support and encourage discussion among members and website to attract the attention of the game’s audience by using http://games.jmir.org/2018/3/e10161/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10161 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Goodman et al can provide places to seek help and emotional support, which There are points to consider when conducting further research can be used to promote behavior change [82,83]. Furthermore, that could have an influence on the development of interventions satisfaction with interventions delivered within virtual to influence health behavior change. First, in recent years, the communities has been found to be significantly higher than that gender gap in those that play video games has narrowed, with in control conditions [84], although inconsistent results have women making up over 40% of the gaming population in the been found for the effectiveness of moderated virtual United States and Europe [90,91]. However, research suggests communities for behavior change [85]. However, previous that many of the games that are developed are hypersexualized research has focused on social networking sites and online and directed toward heterosexual males [92]. Therefore, any patient groups that have typically been set up as interventions intervention development should consider the gender split to for specific studies. Participants in these new communities may ensure that it has the widest possible application. In addition, therefore not have the same level of trust in the moderator that the development of interventions should be mindful of the racist an already established video game–related community might undertones that have appeared in some of the most popular have. Whether virtual gaming communities are used to discuss video games, such as Grand Theft Auto [93]. The stereotypical health information or if interventions delivered within these approach to character development could exclude certain groups communities could promote behavior change needs to be of gamers who may feel judged. This can also extend to explored. individuals who are obese, as research has found that the obesity stigma is not conducive to reducing levels of obesity [94]. Research has also begun to investigate the ability of Therefore, there is a need to be mindful of any stereotypes when 3-dimensional virtual worlds to act as a more immersive form developing interventions. of online social support [86]. Second Life has been studied as one of the most realistic and immersive virtual world’s available Moreover, there should be more investigation about the [87], where people can create and personalize their avatars that distinction between hardcore and casual gamers and how future interact with each other and the environment. There is some interventions could influence each group. Hardcore gamers have evidence to suggest that when people practice health behaviors been described as those that dedicate a large portion of their in the virtual world, they are more likely to transfer this to real leisure time to gaming in comparison with casual gamers [95], life [88]. The dissemination of health information and and so they may be considered more at-risk. However, there is encouragement of positive health behaviors within virtual currently no universal definition to objectively categorize the worlds, like Second Life, could, therefore, prompt behavior gamer type. A move toward better defining groups of gamers change, particularly if accompanied by support from other would enable studies to explore whether interventions should gamers and/ experts in the game [89]. However, there are target differences in how these groups play games as well as massively multiplayer online role-playing games, such as World the type of game and other behavioral factors. However, these of Warcraft and Star Wars: The Old Republic, which offer less issues were not explored and were beyond the scope of this realistic worlds and are instead based on fantasy-oriented worlds. review. Gamers may interact with these games differently with regard Furthermore, although we know that the IGA revenue has risen to health matters, if at all. Gaining a greater understanding of exponentially in the past decade [35], we do not know how how these communities approach both the social aspect of much of this has been spent on the advertisement of HFSS food gaming and health issues may be important for the future and drink products. Future research should investigate the development of interventions for this population. occurrence of HFSS advertisements not only within video games but also in the wider areas related to video games, such as Discussion gaming events and gaming vloggers. This will give an indication of the diversification of the advertising strategy employed by The exponential growth of gaming and its supporting online these companies. communities is a trend that continues to grow—followed by advertising investment—presenting an opportunity to engage In summary, research to date has focused on the development with a key audience. The research outlined in this paper suggests of games specifically designed to change health, but more could that gamers are already exposed to advertisements that be done to explore opportunities within existing online encourage unhealthy behavior both in games and at gaming communities and virtual worlds and utilizing known influencers events. There is, therefore, a need for policy and interventions and methods of advertising to this group. Research in all these to attempt to redress these effects and promote healthy behaviors areas, conducted in a coordinated way with gamers, vloggers, among this group of individuals. and game developers, would offer any interventions their best chances of success. Acknowledgments This work was funded by a BUPA Foundation Fund Innovation Grant from Cancer Research UK (Award reference: C49248/A23538). EM is funded under Health and Social Care Northern Ireland and National Cancer Institute Health Economics Fellowship (Grant: CDV/4980/14). 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[doi: 10.1007/11872320_53] Abbreviations IGA: in-game advertisement HFSS: high fat, salt, or sugar http://games.jmir.org/2018/3/e10161/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10161 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Goodman et al Edited by G Eysenbach; submitted 16.02.18; peer-reviewed by A Amresh, A McDougall; comments to author 05.04.18; revised version received 29.06.18; accepted 06.07.18; published 25.09.18 Please cite as: Goodman W, McFerran E, Purves R, Redpath I, Beeken RJ JMIR Serious Games 2018;6(3):e10161 URL: http://games.jmir.org/2018/3/e10161/ doi: 10.2196/10161 PMID: 30274962 ©William Goodman, Ethna McFerran, Richard Purves, Ian Redpath, Rebecca J Beeken. Originally published in JMIR Serious Games (http://games.jmir.org), 25.09.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/3/e10161/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10161 | p. 10 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

The Untapped Potential of the Gaming Community: Narrative Review

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Abstract

Background: Video gamers are a population at heightened risk of developing obesity due to the sedentary nature of gaming, increased energy intake, and the disruption caused to their sleep. This increases their risk of developing a number of noncommunicable diseases. To date, research seeking to improve health behaviors has focused on developing novel video games to promote behavior change. Although positive results have emerged from this research, large-scale success has been limited due to the lack of transferability to mainstream games and the focus on children and adolescents. The gaming community has a number of unique aspects, which have received comparatively less attention than the development of new video games. Objective: The purpose of this paper is to highlight under-researched areas that have the potential to encourage positive health behavior among this community. Methods: A narrative review of the lay and academic literature was conducted to provide context and support to our claims that further research could be beneficial in this area. Results: Research has found that advertising can have implicit effects on an individual’s memories, which could influence later decisions. However, the effect of the exponential growth of in-game advertisements and the brand sponsorship of gaming events and professional gamers have not been explored in the gaming community. The possibility of using advertising techniques to encourage positive health behaviors within games or at these events has also not been explored. Research suggests that virtual communities can be effective at disseminating health information, but the efficacy of this needs to be explored using known community influencers within the gaming community. Conclusions: This paper has highlighted a number of potential avenues for the development of interventions within the gaming community. Further research must be conducted alongside game developers to ensure that any in-game developed interventions do not deter gameplay and gamers to ensure that potential approaches are acceptable. (JMIR Serious Games 2018;6(3):e10161) doi: 10.2196/10161 KEYWORDS video games; advertisements; health behavior http://games.jmir.org/2018/3/e10161/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10161 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Goodman et al and awareness of health behaviors or by including physical Introduction activity within the game itself. A large body of research has explored the potential to develop games to improve health Background [25-27]. A recent review of systematic reviews found that active Obesity has become a major problem, with an estimated 1.9 video games among children could increase levels of physical billion adults worldwide classed as overweight or obese in 2014 activity and energy expenditure. Health education games also [1]. Furthermore, the growing prevalence of childhood obesity have the potential to support diabetes-related behavior and is now described by the World Health Organization as a major dietary change [28]. However, research in this area has focused challenge of the 21st century [2]. Obesity is linked to an on children and adolescents, whereas the average gamer age is increased risk of developing a number of noncommunicable 35 years in the United States [29]. Furthermore, it is unlikely diseases [3] and is the second largest cause of cancer after that long-standing gamers will be motivated to change their smoking [4]. Previous research suggests those with a higher gaming habits from mainstream video games to active or body mass index are at an increased risk of up to 17 different educational video games. Therefore, additional opportunities cancers [5-7]. An increased intake of energy-dense foods and for interventions targeting gamers should be explored. increasingly sedentary lifestyles are central to the rise in obesity Objective prevalence [1]. The video gamer population is at an increased risk of developing obesity because traditional gaming has now This paper aims to discuss the potential avenues for future become a sedentary behavior. research in this area, drawing on the attributes that are unique to the gaming community. Sedentary behavior is also implicated as an independent risk factor for a number of noncommunicable diseases [3]. Methods Epidemiological studies have found that sedentary behavior is a strong risk factor for the development of endometrial [8,9], This paper comprises a narrative literature review. It draws on breast [10,11], and ovarian [12] cancer in women. In men, lay literature to provide context and descriptive detail and sedentary behavior is a strong risk factor for the development academic literature to support the claims that further research of colorectal (borderline impact for women) [13] and prostate could be beneficial in developing this area for health behavior [14] cancer. Sedentary behavior involves performing activities change. This literature was identified through the following in a sitting or lying position while using low levels of energy, electronic databases: Web of Science, MEDLINE, Google, and and it is considered separate and distinct from a lack of physical Google Scholar. The following keywords were used in various activity [15]. Sedentary behavior includes leisure, work, and combinations: “video games,” “gamers,” “professional gamers,” transportation activities, and it is commonly measured by “gaming events,” “advertising,” “in-game advertisement,” quantifying television viewing, video game use, or general “vloggers,” “forums,” “online communities,” “virtual screen time [16,17]. Research suggests that sedentary behavior communities,” “fast food,” and “marketing.” A snowball method increases the risk of developing obesity [18-20], with those who was also employed, wherein references from relevant papers watch television for more than 20 hours a week more likely to were reviewed to identify other relevant papers. be affected by obesity compared with those who only watch television for 5 hours or less (25% and 14%). Estimates are This review will refer to both hardcore and casual gamers as similar for the use of computers [21]. gamers due to the lack of a universally accepted definition to objectively categorize these 2 groups [30] and the general lack Video games have also been found to increase energy intake of distinction between the 2 groups in research to date. The term among healthy males. A randomized crossover study found that gaming community will be used to cover the areas in which despite increased levels of energy expenditure while playing gamers interact, such as video games, gaming events, online video games (mean energy increase compared with the rest forums, and video blogs. Gamers are extremely heterogeneous, state=89 kJ), this was counteracted by higher levels of energy representing a range of demographic, social, and behavioral intake after playing video games, resulting in an energy surplus groups, and they span international and cultural divides. of 335 kJ compared with those who rested for the same period Understanding the heterogeneity of gamers and their behaviors [22]. Furthermore, video games have been implicated in the and influences and subsequently targeting interventions or disruption of sleep when played before bedtime. Research marketing would provide a rich avenue of research to pursue; involving healthy, good-sleeping adolescents (N=21) found that however, this aspect is not explored in this review. there was a highly significant negative correlation between gaming time and sleep duration (r=−.92) [23]. Shorter sleep Results duration has been associated with an increased risk of weight gain among males, and a higher incidence of obesity was Several aspects of gaming that could be utilized to engage observed in males with shorter sleep duration [24]. Those who gamers in health behavior change, including gaming play a large number of video games may, therefore, represent environments, virtual communities, and community influencers, an at-risk population that could benefit from targeted were identified. These features and their ability to be applied interventions. to health behavior change are described and discussed below. The majority of previous research involving gamers has focused solely on the potential for video games to be used as a medium for health behavior change, either by increasing the knowledge http://games.jmir.org/2018/3/e10161/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10161 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Goodman et al to add menu items that appeal to the 18- to 34-year-old In-Game Advertisement demographic and expand late-night sales” [49]. Dynamic IGAs, Companies use marketing to connect consumers with their such as those used by Wendy’s, can cost around US $4-12 per products and services [31]. There is a range of marketing 1000 impressions received (1 impression=the advertisement strategies and tools that companies can employ to promote their being on screen for 10 seconds). Static IGAs that cannot be brand, with advertising being one of the more expensive changed once the game has been released can cost between US approaches. In in-game advertisement (IGA), companies pay $50,000 and $500,000 [50]. to have their brand promoted within a game itself [32,33]. In 2004, companies spent US $34 million on IGA [34]; this Banning HFSS advertisements in games may be more difficult spending grew exponentially to US $3.1 billion in 2011 and than with television or the internet, as such a ban cannot be was expected to reach US $7.2 billion in 2016 [35]. This can targeted at a certain age bracket and a blanket ban approach occur in different forms such as posters or billboards within the may be considered heavy-handed. This ban may also not be game environment, food that is consumed by a character, or possible in certain countries that have laws guaranteeing having a character dressed in branded clothing [36]. However, freedom of speech, such as the United States. However, it may not all games lend themselves to IGA, and it is often only be possible for video games to be utilized in a different way to included if it is seen as congruent with the game. With the rise combat IGA of HFSS. If funds were available, charities (eg, of mobile gaming, advertisements have also started appearing Cancer Research UK or Diabetes UK) could consider in apps at the top or bottom of the phone screen or as short video counteradvertising and place their own IGA’s, which could clips between levels [37]. These advertisements can be target people directly with health-promoting messages or personalized to the user through the use of metadata collected information. Within a collaborative context where charities and by search engines, social media companies [38], and mobile game developers share values on an approach, content of such apps [39], which is thought to make them more effective at premium games could be developed or adverts may be targeted reaching their target audience [40,41]. toward health behavior change to influence implicit memory in gamers. This could be a viable alternative when regulation is Research has found that IGAs have a strong effect on our not an option. Research has shown that gamers develop negative implicit memory. For example, 1 study found that participants attitudes to advertisements that are intrusive and incongruent who played a Formula 1 video game scored significantly higher with the game, as it reduces their sense of realism [51,52]. There on a word-fragmentation task of brand names (that were shown is, therefore, a need for developers willing to take up the in the video game) than those in a control condition [42]. The challenge to show how positive advertisements may be authors concluded that these effects on implicit memory could effectively included in games to support healthy behaviors and in turn influence later decisions. Research has shown this to be choices. the case for television advertising; for example, studies have shown that television advertising for unhealthy food increases Further Promotional Techniques positive attitudes toward junk food in children [43] and increases Brands have diversified their promotional mix beyond food consumption and time spent eating food among adults advertisements to target the gamers in other unique ways. Viral [44]. Interestingly, these studies also found that advertising marketing techniques utilize the internet and already established nutritious food showed an increase in positive attitudes toward social networking services and sometimes community healthy food and less consumption of food in general. influencers to popularize a brand [53]. Burger King teamed up In 2007, Ofcom, the communications regulator for the United with Sony Spain to offer the delivery of fast food to gamers who Kingdom, introduced a ban on television advertisements of high signed up to play with professional gamers online. After fat, salt, or sugar (HFSS) food or drink products for children’s completing a game, the professional gamer would then take the airtime to reduce the exposure of children aged less than 16 order and it would be delivered to the gamer’s door [54]. Viral years to unhealthy foods [45]. The effectiveness of this ban marketing campaigns have been found to be effective tools for provided an estimated reduction in children’s exposure to HFSS the promotion of a brand [53]. Brands have attempted tie-ins advertisements by 37% in 2009 compared with 2005 [46]. with newly released games by offering discounts and prizes to However, with a migration of viewing habits to Web-based people that buy their products. For example, with the release providers, children could still be exposed to HFSS advertising. of the Call of Duty: Black Ops III, gaming prizes including In 2016, a ruling by the UK advertising regulator extended these Double XP could be won by buying special Mountain Dew and restrictions to all nonbroadcast media for children aged less Doritos products [55]. Research has found that the use of than 16 years or that have an audience made up of 25% of promotions for well-known brands can have a positive impact children aged less than 16 years [47]. Although a piece of on its long-term sales prospects [56]. The use of viral marketing legislation was expected to come forward in 2017 to address and promotions by companies seeking to market their brands this, video games were still not covered, and therefore, cannot be stopped; however, their association with large individuals were still exposed to IGA. For example, Wendy’s companies such as Sony can be targeted. In recent years, (a burger chain operating primarily in North America) is set to corporate social responsibility has become increasingly have an IGA for their Baconactor (a 950-calorie burger) on important to both the consumer and the company [57]. It can billboards, bus shelters, and television screens within the virtual affect the way that consumers evaluate a brand and can act as gaming systems of multiple games spanning Xbox, PlayStation protection for a company in times of crisis [58,59]. Therefore, 4, and personal computer platforms [48]. Information on the the encouragement of collaborative work between health product claims, “The addition of the product was part of a push http://games.jmir.org/2018/3/e10161/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10161 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Goodman et al researchers, charities, and corporations would help to serve both the gamer as an advertisement [67]. Celebrities have been found sides. to be effective mediums for advertisements of energy-dense and nutrient-poor food products, both for children [68] and Gaming Events adults [69]. This effect is thought to be due to celebrities Gaming events where gamers and developers gather to play, conferring an implicit benefit and by establishing positive demonstrate, and discuss games are an extension of the gaming associations with the brand through the transference of qualities community. They offer additional opportunities for promoting of physical appeal and likeability from themselves to the product health messages and engagement with audiences. A number of [70,71]. Again, the absolute removal of this incentive and these events attract the video game community, such as comic investment involved for professional gamers might not be book conventions, gaming festivals, and eSports tournaments. achieved easily, as they are often reliant on sponsorship to These typically feature high numbers of sponsors and support their career [72]. Nonetheless, attempting to harness promotions for energy drinks, fast food, and other high-calorie this influence within the community may help to counterbalance foods [60]. unhealthy advertisements. For example, attempting to use the gamers’ influence to create positive attitudes to health behaviors eSports are video gaming competitions involving mostly may be a viable option. professional gamers that contend for prize money. These events are frequently broadcast on television and streamed live over Game-related video bloggers (vloggers) have become the internet. The final for the League of Legends (a multiplayer increasingly popular among gamers. These vloggers post videos online battle arena video game) 2015 World Championship of themselves playing games and giving commentary, glitches drew a global audience of 36 million viewers [61], which was within games, reviews of games, formal walkthroughs of games, greater than the 2016 NBA final that drew 31.2 million viewers using video games to create films from the content, and speed [62]. eSports events have a range of brands that are marketing runs of people completing things in the fastest time [73]. An partners and sponsor both the events and teams. This is a further individual known as PewDiePie is the most popular vlogger on promotional technique to increase brand recognition and YouTube with over 54 million subscribers to his channel and generate positive publicity within the gaming community. The was the first YouTube star to reach over 10 billion views; his energy drink Red Bull, in particular, has a strong brand presence popularity came from his commentary of video games [73,74]. in eSports by sponsoring some of the biggest tournaments, PewDiePie’s popularity offers significant influence with an teams, and clubs [63]. Monster Energy drink, along with Papa engaged audience, with reports of increased game sales when John’s Pizza, sponsors the most successful video gaming team a positive video is posted of the game on his channel [75]. This in the world, Evil Geniuses [64]. This suggests that these events influence has been found to extend to charity give advertisers a unique ability to target and engage gamers. fundraising—raising almost $500,000 for Water Campaign by Although removing brand investment from these events may encouraging subscribers to donate [76], demonstrating the be difficult, as with IGA, it may be of significant value to potential of these influencers to encourage positive behaviors explore promoting advertisements with positive nutrition outside of gaming. messages or conducting health and health behavior seminars in The effect of this influence among online communities is borne the downtime between eSports matches to balance out the effects out in research, which suggests that these influencers provide of other advertisers. In addition, the development of guidelines an important role in the social discourse: encouraging discussion or regulations for food choice management during these events and interaction between members, arranging events, and keeping could encourage organizers to expand the range of food and site content up-to-date [77]. Zhang and Dong [78] have drink choices on offer. Providing incentives, vouchers, or tokens suggested that these influencers can have a lot of sway over the to eat healthier foods (which could be funded through opinions of community members but that this is dependent on ticket-pricing adjustments) could also help modify choice, their ability to engage the community through sociability and moving to a distinct nudge toward healthy eating among this the extent of their knowledge and innovation. Therefore, much community [65]. Initial work might explore the appetite for as with professional gamers, utilizing these community health marketing at these events and the methods to quantify influencers could help to shape opinions on healthy behavior the potential effects for the video game community. among gamers. Community Influencers Virtual Communities Among many communities, there are those who are considered The aforementioned online social communities have developed influencers—individuals who have a greater amount of influence in conjunction with many video games [79]. Individuals use over members’ commitment [66]. Professional gamers have these communities to discuss the game and share ideas and goals emerged as influencers within the gaming community by without the constraints of geographical location [80]. The most becoming the best gamers within their respective gaming genres, frequent gamers, who tend to play multiplayer and online games, and they appear to be styled as celebrities of the gaming can play with other gamers online for an average of 6.5 hours community [60]. These professional gamers receive investment a week and in person for 4.6 hours a week [81], suggesting that from companies and in turn wear clothes with the company’s the social aspect of gaming plays an important role for those logos for matches, in the same way as active sports such as engaged in these communities. Virtual communities have been soccer or tennis. They make videos promoting products and found to be effective mediums to disseminate health information. play video games that are live-streamed on the company’s They support and encourage discussion among members and website to attract the attention of the game’s audience by using http://games.jmir.org/2018/3/e10161/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10161 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Goodman et al can provide places to seek help and emotional support, which There are points to consider when conducting further research can be used to promote behavior change [82,83]. Furthermore, that could have an influence on the development of interventions satisfaction with interventions delivered within virtual to influence health behavior change. First, in recent years, the communities has been found to be significantly higher than that gender gap in those that play video games has narrowed, with in control conditions [84], although inconsistent results have women making up over 40% of the gaming population in the been found for the effectiveness of moderated virtual United States and Europe [90,91]. However, research suggests communities for behavior change [85]. However, previous that many of the games that are developed are hypersexualized research has focused on social networking sites and online and directed toward heterosexual males [92]. Therefore, any patient groups that have typically been set up as interventions intervention development should consider the gender split to for specific studies. Participants in these new communities may ensure that it has the widest possible application. In addition, therefore not have the same level of trust in the moderator that the development of interventions should be mindful of the racist an already established video game–related community might undertones that have appeared in some of the most popular have. Whether virtual gaming communities are used to discuss video games, such as Grand Theft Auto [93]. The stereotypical health information or if interventions delivered within these approach to character development could exclude certain groups communities could promote behavior change needs to be of gamers who may feel judged. This can also extend to explored. individuals who are obese, as research has found that the obesity stigma is not conducive to reducing levels of obesity [94]. Research has also begun to investigate the ability of Therefore, there is a need to be mindful of any stereotypes when 3-dimensional virtual worlds to act as a more immersive form developing interventions. of online social support [86]. Second Life has been studied as one of the most realistic and immersive virtual world’s available Moreover, there should be more investigation about the [87], where people can create and personalize their avatars that distinction between hardcore and casual gamers and how future interact with each other and the environment. There is some interventions could influence each group. Hardcore gamers have evidence to suggest that when people practice health behaviors been described as those that dedicate a large portion of their in the virtual world, they are more likely to transfer this to real leisure time to gaming in comparison with casual gamers [95], life [88]. The dissemination of health information and and so they may be considered more at-risk. However, there is encouragement of positive health behaviors within virtual currently no universal definition to objectively categorize the worlds, like Second Life, could, therefore, prompt behavior gamer type. A move toward better defining groups of gamers change, particularly if accompanied by support from other would enable studies to explore whether interventions should gamers and/ experts in the game [89]. However, there are target differences in how these groups play games as well as massively multiplayer online role-playing games, such as World the type of game and other behavioral factors. However, these of Warcraft and Star Wars: The Old Republic, which offer less issues were not explored and were beyond the scope of this realistic worlds and are instead based on fantasy-oriented worlds. review. Gamers may interact with these games differently with regard Furthermore, although we know that the IGA revenue has risen to health matters, if at all. Gaining a greater understanding of exponentially in the past decade [35], we do not know how how these communities approach both the social aspect of much of this has been spent on the advertisement of HFSS food gaming and health issues may be important for the future and drink products. Future research should investigate the development of interventions for this population. occurrence of HFSS advertisements not only within video games but also in the wider areas related to video games, such as Discussion gaming events and gaming vloggers. This will give an indication of the diversification of the advertising strategy employed by The exponential growth of gaming and its supporting online these companies. communities is a trend that continues to grow—followed by advertising investment—presenting an opportunity to engage In summary, research to date has focused on the development with a key audience. The research outlined in this paper suggests of games specifically designed to change health, but more could that gamers are already exposed to advertisements that be done to explore opportunities within existing online encourage unhealthy behavior both in games and at gaming communities and virtual worlds and utilizing known influencers events. There is, therefore, a need for policy and interventions and methods of advertising to this group. Research in all these to attempt to redress these effects and promote healthy behaviors areas, conducted in a coordinated way with gamers, vloggers, among this group of individuals. and game developers, would offer any interventions their best chances of success. Acknowledgments This work was funded by a BUPA Foundation Fund Innovation Grant from Cancer Research UK (Award reference: C49248/A23538). EM is funded under Health and Social Care Northern Ireland and National Cancer Institute Health Economics Fellowship (Grant: CDV/4980/14). 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[doi: 10.1007/11872320_53] Abbreviations IGA: in-game advertisement HFSS: high fat, salt, or sugar http://games.jmir.org/2018/3/e10161/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10161 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Goodman et al Edited by G Eysenbach; submitted 16.02.18; peer-reviewed by A Amresh, A McDougall; comments to author 05.04.18; revised version received 29.06.18; accepted 06.07.18; published 25.09.18 Please cite as: Goodman W, McFerran E, Purves R, Redpath I, Beeken RJ JMIR Serious Games 2018;6(3):e10161 URL: http://games.jmir.org/2018/3/e10161/ doi: 10.2196/10161 PMID: 30274962 ©William Goodman, Ethna McFerran, Richard Purves, Ian Redpath, Rebecca J Beeken. Originally published in JMIR Serious Games (http://games.jmir.org), 25.09.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/3/e10161/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10161 | p. 10 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Sep 25, 2018

Keywords: video games; advertisements; health behavior

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