Title: Responsible Gambling: a mixed methods analysis to inform public health policy and practice
Funder: Department of Health and Social Care

Abstract: Background: Changes in the scale and nature of gambling in the UK have created growing concerns about its impact on health, especially in already vulnerable groups. An estimated 430,000 adults and 55,000 youths experience problem gambling, with many more deemed to be at risk. Research gap: Existing responses are based on the paradigm of 'Responsible Gambling', seeking to maximise individual freedom to access gambling opportunities while minimising harm. Yet, despite its endorsement by the Government and gambling industry, there are growing calls for a stronger public health response. However, the process by which such a response would be developed, in terms of policy-making and prioritisation of research on gambling is unclear, as are the social determinants of gambling and the interventions that might be effective within a comprehensive public health response. Fellowship proposal: My proposal responds directly to these gaps. I want to understand the socioeconomic determinants of gambling, the measures likely to be effective in alleviating the associated harms, and the scope for implementing them (and the barriers to doing so), both within local authorities and in national policy.To achieve this, I will take a multi-level approach using a range of methods. This will involve: A systematic review of the quantitative and qualitative literature on gambling interventions, building upon previous reviews by using both quantitative and qualitative studies to understand not just what works but how and in what circumstances. Identifying the determinants of gambling consumption using regression analysis of the association between changes in household gambling expenditure and changes in local spending and job loss, and how this differs between socio-economic groups. Identify the influences on the response to gambling regulation within local authorities, considering how this issue reaches the policy agenda, why it is or is not prioritised, and the nature of any responses, including an understanding of factors that support or hinder cross-sectoral working. This will employ semi-structured interviews with stakeholders in public health, licencing and planning departments as well as elected members. Informed by my literature review and understanding of the approaches taken by local government and, in particular, public health departments, undertake a stakeholder analysis and interviews, to identify the positions of key policy actors, employing quantitative and qualitative methods of textual analysis to explore how they frame gambling policy and the influence this has on how they respond to gambling harms. Integrating the research findings to develop, through co-production with stakeholders, a framework for a multi-level public health response and future research agenda in the UK.I will place PPI at the centre of my research, engaging with those affected by gambling to help me frame and refine the questions I ask, of whom, and how I interpret the answers. I will share my findings with key stakeholders, in particular policy-makers, public health researchers and practitioners, using briefing papers, fact sheets, presentations and short films co-produced with affected individuals. My proposed fellowship has been designed to complement other research on gambling currently being undertaken within the UK.

Lay abstract: The problem: In the past decade, the scale and nature of gambling in the UK has changed enormously. The 2005 Gambling Act liberalised controls on gambling outlets and advertising while the internet has greatly increased opportunities to place bets. These developments have coincided with a large increase in the amount spent on gambling, and in particular what is termed problem gambling. At the same time, the consequences of this spending, especially as it affects some of the most vulnerable people, has raised concerns about the impacts on health. For example, with debt, job loss, and family and relationship breakdown leading to mental illness and intimate partner violence.1,2 Data from the Gambling Commission estimated that, in 2016, 430,000 adults were problem gamblers, with millions more at risk of harm. A 2018 survey estimated that 55,000 11-16 year olds were problem gamblers. Although gambling is portrayed by the Government and the gambling industry as a leisure activity, gambling can sometimes be seen as a means of escape from difficult financial circumstances so further losses can easily lead to a vicious downward spiral.3-5 NHS Chief Executive Simon Stevens has identified gambling addiction as a 'new threat' to the NHS, demanding a response that is 'more serious about aspects of prevention in public health'.6 Speaking on behalf of a cross-party group of MPs and peers, the shadow culture secretary, Tom Watson, has stated that 'Gambling addiction is Britain's hidden epidemic. It's time to start treating this as the public health crisis it is.'7 Unfortunately there is limited evidence about what is needed for an effective public health response. Why and what research is needed: English local authorities now play a key role in responding to the health consequences of gambling. Yet if they are to mount an effective public health response to gambling harms, the public health community and others need much more evidence on the health consequences and corresponding responses to gambling in the UK. Specifically, we need research on: What drives gambling uptake and how this differs between groups? What local and national-level interventions are effective at preventing gambling harms? How do key stakeholders frame gambling and responses to it? What lessons can be learned from how different local authorities approach gambling regulation, especially in the context of budget cuts.Fellowship proposal: My aim is to contribute to filling these gaps, thereby assisting the public health community and others, to design and monitor a public health response to gambling that benefits the UK population.I will do this in 4 ways: Systematically review the literature on gambling interventions, building upon previous research by exploring not just what works but how and in what circumstances. Identify drivers of gambling uptake, by examining the complex relationship between household spending on gambling and cuts to services and unemployment, and how this differs between certain groups. Identify the factors that shape approaches to gambling regulation and how it is framed and prioritised in different local authorities, by interviewing key stakeholders in public health, licencing and planning departments of local authorities and local Councillors. Evaluate the factors influencing gambling policy and research agendas nationally, based on interviews with key decision makers and analysis of policy documents, with a focus on how evidence is used. My research will place patient and public involvement (PPI) at its core, ensuring that those affected by gambling help to shape the questions being asked and how they are framed, while also involving them fully in summarising and dissemination of results, for example through public meetings, fact sheets, multi-media presentations, and other means.

Research activity codes: 2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS;8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: MENTAL HEALTH