Walk down any Japanese street and, amid the rush of people and cars, you can usually hear a very particular thump and clang. Gaming parlor machines. And more often than not, the patrons are playing pachinko — pulling tiny levers of what look like upside-down pinball machines spewing teensy silver pellets. The balls are exchanged for gifts that are swapped across the street for cash. And the Japanese are addicted.

According to the nation’s Ministry of Health, Labor and Welfare, 4.8% of Japan’s adult population suffers from pathological gambling, much of it pachinko playing.

In Korea, that figure is just 0.5 percent, says Keith S. Whyte, executive director of the National Council on Problem Gambling — ironic, since most Japanese gambling parlors are owned by ethnic Koreans. What are the consequences of gambling addiction in Japan? Substance abuse, crime and greater rates of mental illness, just like anywhere. But according to Dr. Timothy Fong, director of UCLA’s gambling studies department, the Japanese may be prone to developing gambling addictions because of their surroundings and may then have a harder time overcoming addiction than others. There’s also the soothing aspect of addiction: Since Japan’s culture values keeping emotions in check, citizens are more likely to self-medicate with gambling, as they do with alcohol. “Japanese hate gambling but have an urge to do it. At the beginning, it felt good. Once they’re an addict, they can’t stop,” Fong says.

It’s also easier for the Japanese to gamble because machines are everywhere. There are 2.79 million machines as of 2013, compared with fewer than a million slots in the United States. And because they operate in a gray legal space of “entertainment,” pachinko operators can place them in any neighborhood and advertise on TV at any hour.

Ken Winters, director at the Center for Adolescent Substance Abuse Research in Minneapolis, says that genetics, personal attributes, the environment and the interaction of these factors contribute to addictions, but that he has “no basis to judge whether citizens of Japan are at higher or lower risk compared to other citizens of other countries.” In regard to cultural shaming, he says the same thing: “It’s human nature to experience shame when a person has lost a lot of money due to gambling.”

Some countries with thriving gambling cultures, says Fong, lack high addiction rates. In New Zealand, for example, mental health professionals walk around casino floors looking to help people! But cultures in which shaming plays a big social role tend to have problems with gambling as much as they do with depression, says Dr. Lia Nower, director of the Center for Gambling Studies at Rutgers. While the Japanese and Chinese are surrounded by gambling cultures, India is not, and yet all suffer from high rates of addiction, with “[the Japanese and Chinese] feeling they should be able to control their gambling. And [Indian] families feel they shouldn’t be doing it at all,” Nower says. Public health programs à la New Zealand to the rescue, right? Think again. They’re surprisingly hard to find in countries that actually need them.

Some psychiatrists challenge the idea of environment when it comes to gambling addiction. Genetics, they say, play just as important a role, even if a person lives in a healthy environment. An impulsive personality trait, for example, can lead to addiction if the person is interested in gambling. But Fong says genetics can be overcome. In the right environment and with the right level of support, even the most genetically prone gambler can avoid addiction. Game on?