Tackling gambling related harms as a public health issue
Authors: Elizabeth Goyder, Lindsay Blank, Susan Baxter, May CI van Schalkwyk
Journal: The Lancet Public Health (2019)

Gambling is a highly profitable commercial activity, with providers including international corporations and governments. However, there is growing international recognition that gambling is a source of serious harm, and that there is inequity in the distribution of this harm, which has led to demands for action to protect public health. These concerns are reflected in the recent report from the UK All-Party Parliamentary Group,1All-Party Parliamentary GroupOnline Gambling Harm Inquiry.http://www.grh-appg.com/wp-content/uploads/2019/11/Interim-APPG-Report-November-final.pdfDate: 2019Date accessed: November 14, 2019Google Scholar which calls for stronger action on regulation of online gambling. Although there is largely a consensus on the need for developing and implementing strategies to reduce gambling-associated harms, to date, the stated need for a public health approach to preventing harm has not been widely or effectively translated into action in the UK.2Wardle H Reith G Langham E Rogers RD Gambling and public health: we need policy action to prevent harm.BMJ. 2019; 365l1807Crossref PubMed Scopus (119) Google Scholar The barriers and facilitators to effective public health action need to be understood to enable good intentions to be translated into effective action. The current context represents real opportunities for policy implementation, but also the threats to effective action that need to be addressed. There is often limited support for measures that reduce an individual's freedom to choose their own recreational activities, even when the trade-offs include benefits to public health and reduced inequalities.3Reynolds JP Archer S Pilling M Kenny M Hollands GJ Marteau TM Public acceptability of nudging and taxing to reduce consumption of alcohol, tobacco, and food: a population-based survey experiment.Soc Sci Med. 2019; 236112395Crossref PubMed Scopus (47) Google Scholar However, increasing public concern about the effects of gambling on children, sponsorship of popular sports by gambling companies, and the introduction of gambling elements in online gaming (including so-called loot boxes) could provide an opportunity to ensure public support for regulation and restrictions that reduce industry marketing and introduce age limits for more forms of gambling. The debate, and subsequent legislation to reduce maximum stakes on fixed odds betting in the UK, showed the potential for widespread, cross-party political support for measures that addressed a specific public concern that disproportionately harmed the most vulnerable in society. However, even here, there was a threat posed by vested interests to take action and to use, later discredited, data.4Davies R Government's FOBT decision influenced by 'discredited' report.https://www.theguardian.com/uk-news/2018/nov/12/government-fobt-decision-discredited-reportDate: Nov 12, 2018Date accessed: November 14, 2019Google Scholar Although television and other media provide a channel for gambling promotion and activities, popular television shows (eg, The Simpsons) have also addressed the risks of gambling addiction. Media coverage tends to focus on the extremes, such as big wins and the extremes of harm associated with debt (eg, suicides and criminal convictions).5Turner NE Fritz B Zangeneh M Images of gambling in film.J Gambl Issues. 2007; 20: 117-143Crossref Google Scholar Public awareness of the spectrum of harm is therefore relatively low in comparison to tobacco or alcohol, for which the appreciation that there is no universally safe threshold for consumption is greater.6Monaghan SM Derevensky J An appraisal of the impact of the depiction of gambling in society on youth.Int J Ment Health Addict. 2008; 6: 537-550Crossref Scopus (34) Google Scholar Although reviews of the evidence directly related to gambling harm are currently underway, there is already increasing evidence from other sectors that a public health approach that includes fiscal measures and reduces exposure to advertising and access to harmful commodities could reduce population level harm. The introduction of restrictions on marketing and increasing taxation on the products associated with higher risks of harm have been used to reduce tobacco, alcohol, and sugar-sweetened drink consumption.7Chaloupka FJ Powell LM Warner KE The use of excise taxes to reduce tobacco, alcohol, and sugary beverage consumption.Annu Rev Public Health. 2019; 40: 187-201Crossref PubMed Scopus (90) Google Scholar, 8He Y Shang C Huang J Cheng KW Chaloupka FJ Global evidence on the effect of point-of-sale display bans on smoking prevalence.Tob Control. 2018; 27: e98-e104Crossref Scopus (25) Google Scholar These examples should give policy makers confidence that similar policies for gambling would also be effective if successfully implemented. However, substantial threats exist given the range of vested interests in the gambling field. Experience in New Zealand shows the obstacles to policy changes to restrict or regulate a highly profitable industry.9Adams PJ Rossen F A tale of missed opportunities: pursuit of a public health approach to gambling in New Zealand.Addiction. 2012; 107: 1051-1056Crossref PubMed Scopus (27) Google Scholar The complex nature of the gambling environment and factors that influence both individual gambling behaviour and risk of harm means that policy change could lead to both the industry and individuals changing their behaviour in unpredictable ways.10Knai C Petticrew M Mays N et al.Systems thinking as a framework for analyzing commercial determinants of health.Milbank Q. 2018; 96: 472-498Crossref PubMed Scopus (66) Google Scholar When access is restricted or stakes reduced for a specific form of gambling, unintended consequences are likely to include an increase in other forms of gambling. This consideration serves as a strong rationale for a policy approach that, as well as targeting specific forms of gambling, includes system-wide interventions and for ensuring that all policies are evaluated for both the intended and unintended consequences. Research is needed to understand the complex interactions between the availability and uptake of gambling activities and the related harms. A greater understanding is also needed of what gambling policies have been adopted and why, and what evidence and interests have informed the policy-making process to date. The main threat to a public health approach is the potential for the gambling industry and other vested interests to oppose or subvert any policies that might reduce profits. The complexity of the systems on which policies act means any policy must be carefully evaluated for both intended and unintended consequences, and the independence of evaluation prioritised and protected. In the meantime, there is already evidence from other commercial sectors (eg, tobacco, alcohol, and sugar-sweetened drinks) that effective action is possible and also broad public support for addressing the risks, particularly to children. There is a real opportunity for delivering an evidence-based public health approach to gambling-related harm. EG, LB, and SB are supported by the National Institute for Health Research (NIHR) Public Health Research Programme. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. We declare no competing interests.