Public Health Perspectives on eSports

Electronic sports (eSports) are sports facilitated by electronic systems and in which players and teams interact in eSports activities through human–computer interfaces. ¹ eSports began as arcade video games in the 1980s, and their forms evolved in the internet era. ² The term “eSports” commonly refers to organized video game competitions (both professional and amateur levels). ^1,3,4 Video games have evolved from a hobby to an organized sport. eSports have components that are similar to other sports: players, spectators, referees, agents, leagues, tournaments, sponsorships, and the culture of professional game play. ⁵

eSports has transformed traditional video games into a medium of sports competitions. In 2012, South Korea, a major hub of eSports in Asia, had more than 430 professional eSports players or eSports athletes. ⁶ Because eSports players are considered athletes (both professional and amateur), eSports competitions are regarded more seriously than recreational gameplay. During 2010-2012, worldwide prizes for the top 10 eSports games totaled more than $18 million. ⁶ More than 70 million spectators were estimated to watch eSports in 2013. ¹ Spectators can attend eSports competitions at an arena or via live streaming on their personal devices. ⁷ The eSports market has been steadily growing; the global eSports market, including sponsorships, advertising, media rights, game publisher feed, tickets, and merchandise, increased by at least 37%, from $655 million in 2017 to >$900 million in 2018. ⁸ eSports was accepted to be a medal event in the 2022 Asian Games and might be added as an official sport in the 2024 Olympic Games. ^9,10

Sports have long been advocated by the public health community as a way to improve health among populations. ¹¹ Unlike most traditional sports, which require physical activity, however, both professional and amateur eSports players spend their game time sitting in front of computers, mobile devices, or monitors during training and competitions. Moreover, a large number of spectators engage in eSports activities as sports fans or followers. The increased popularity of eSports has led to several emerging topics of discussion; for example, consideration of eSports as a traditional sport, eSports spectatorship, and the eSports market. ^1,4,6 To our knowledge, eSports have not generally been discussed in the public health sector. We propose several ideas for raising awareness and increasing understanding of eSports and eSports-related health concerns among the public health sector.

Video Game–Related Illnesses and Injuries

Video games can cause illnesses and injuries. Prolonged playing of video games increases the risk of repetitive strain injuries, seizures among persons with epilepsy or photosensitivity, injuries due to distractions from the real world (eg, injuries incurred while using mobile devices), and criminal incidents (eg, injuries incurred while playing games in a dangerous or inappropriate place). ^{12 -14} On the professional level, eSports may lead to work-related illnesses, such as occupational overuse syndrome due to repetitive movements, overuse of muscles and inappropriate postures, and computer vision syndrome or video game vision syndrome. ^15,16

The public health sector should focus on injury prevention, safety issues, and occupational health of eSports athletes and spectators. Currently, most popular eSports games, such as FIFA 19 (a football simulation video game), League of Legend (a multiplayer online battle arena), DOTA 2 (Defense of the Ancients 2, also a multiplayer online battle arena), and Arena of Valor or Realm of Valor (also a multiplayer online battle arena), are typically played by gamers who sit and concentrate while viewing computer or mobile device screens. The health concerns of eSports athletes may not differ from the health concerns of office workers who use computers. However, if exergames (video games such as tennis, which require players to exercise) become part of eSports on the professional level, players will have to perform physical activities through the virtual world. Exergames competitions can lead to injuries that are similar to injuries that occur in real-world sports.

Sedentary Behaviors

Performing tasks while sitting in front of a device screen is considered a sedentary behavior. ¹⁷ A systematic review and dose–response meta-analysis showed that spending more than 6-8 hours per day sitting or 3-4 hours per day watching television significantly increases the risk of all-cause mortality and cardiovascular disease mortality. ¹⁸ Another study, on the movements of 115 elite eSports athletes, showed that these athletes spent about 5.3 hours per day in training (including 1.1 hour per day of physical exercise). ¹⁹

An eSports athlete could spend a considerable amount of time in sedentary activities. This unhealthy behavior is a challenge for the public health sector. However, the aforementioned study of 115 eSports athletes found that 64.3% (n = 74) engaged in physical exercise more than 1 hour per day, which meets the level of physical activity recommended by the World Health Organization and other international organizations. ^{19 -21} More than half (55.6%, n = 64) of the eSports athletes investigated in that study believed that physical exercise in their training programs could affect their performance. ¹⁹ This concept may be a good catalyst to promote physical activity among eSports athletes .

Mental Illness

The effects of video games on mental health can be a double-edged sword. On the positive side, video games aim to make recreational activities fun for players. On the negative side, excessive video game playing can cause mental health problems, including sleep disorders, mood disorders, and poor work performance. ^22,23 The most recent Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition includes a game addictive behavior, internet gaming disorder, as a new diagnosis. ²⁴

The high levels of training and competition in eSports could lead to stress, mental illness, and poor decision making. The violence portrayed in the virtual world of games may translate into aggressive behavior and disinhibition in real-life situations. ^25,26 Anyone can join the eSports community at any age, and some adolescents have expressed a desire to leave school to become eSports experts. ^27,28 To prevent mental health issues, eSports team and staff members can provide social and emotional support for eSports athletes. ^29,30 eSports-related mental health is an issue that the public health sector cannot ignore. Moreover, recommendations on eSports should be developed and promulgated by public health authorities, including, for example, suggestions for parents, guardians, and teachers to monitor children and adolescents.

Drug Use and Doping

Performance-enhancing drugs is a common term in the sporting world. Sporting organizations (eg, the International Olympic Committee and the World Anti-Doping Agency) monitor the use of illegal and banned substances before, during, and after competitions. If eSports become part of national or international sporting organizations, these bodies would need to enforce rules, including anti-doping rules, to ensure safe and ethical conduct in eSports.

The public health sector can extend its role in the fight against the use of illegal substances and the misuse of prescribed and over-the-counter drugs into the eSports world. For example, athletes may use stimulants to boost their concentration and improve their reactions. They may use anxiolytic medications and beta-blockers to maintain a feeling of calm under pressure. Although no evidence exists to show that eSports players use drugs to strengthen their gameplay, educating athletes and all relevant parties in the eSports world on the use and misuse of drugs is essential.

Gambling

Sports gambling is a major business enterprise worldwide; it is legal in some countries, but it is illegal or considered unethical in others. In the present digital era, the physical borders of countries seem meaningless. Online gambling is common in the sporting world. An online search on December 8, 2018, using the search term “eSports gambling” produced nearly 11 million results. Gamblers can choose any site on which to gamble. Some video games offer the purchase of virtually randomized items that use real-world money called “loot boxes.” Items received from the loot boxes may help customize game characters to become more attractive or progress in the game. These loot boxes are associated with problem gambling. ^31,32 Gambling is a health-risk behavior and a public health concern in countries around the world. ^{33 -35} It can cause emotional distress, psychological distress, and other illnesses because of an increase in health-risk behaviors, such as inadequate sleep, smoking, alcohol consumption, poor nutrition, and criminal activities. ³⁶

It is beyond the authority of the public health sector to regulate anti-gambling rules as they relate to eSports. However, public health authorities can help promote awareness of and educate the public about the adverse health consequences of eSports-related gambling.

Conclusion

The increased popularity of eSports affects many aspects of society, including public health. Health-related issues of eSports athletes and spectators should be a public health concern. The public health sector should follow the development of eSports and explore the behavior and health issues of athletes and spectators as eSports develop. Supportive programs for eSports players and spectators should be designed and implemented, health guidelines or recommendations should be written and promoted, and public awareness of the health consequences of eSports should be expanded. Research on the effects of eSports on health is lacking. Further study is needed to facilitate an evidence-based approach to understanding and managing the health consequences of eSports.