The Lancet Public Health Commission on gambling
Authors: Heather Wardle, Louisa Degenhardt, Audrey Ceschia, Shekhar Saxena
Journal: The Lancet Public Health (2021)

Gambling is pervasive in society and is provided by increasingly powerful supra-national corporations, whose reach transcends national boundaries. The development of commercial gambling practices is deeply tied to technological development, and leaps in communication technologies have resulted in the expansion of commercial gambling.1Reith G The age of chance. Routledge, London1999Google Scholar This pattern is also evident with online infrastructure, where the development of smart phone technology and increased accessibility and speed of access to the internet has generated new gambling products that were previously unavailable (eg, in-play betting). As technology continues to develop, so will the commercial gambling sector. For example, 5G capabilities will increase the strength and speed of connections between consumers and corporations and could be one of the next major innovations to expand the reach of gambling corporations. Gambling companies are seeking to learn from gaming industries about how to attract and retain customers, while gambling-like activities have, controversially, been introduced into some games.2Drummond A Sauer JD Hall LC Zendle D Loudon MR Why loot boxes could be regulated as gambling.Nat Hum Behav. 2020; 4: 986-988Crossref PubMed Scopus (16) Google Scholar Yet gambling is no ordinary activity. It is risk-based and health harming. Gambling can harm the health and wellbeing of individuals, families, communities and society.3Wardle H Reith G Langham E Rogers RD Gambling and public health: we need policy action to prevent harm.BMJ. 2019; 365l1807Crossref PubMed Scopus (73) Google Scholar These harms are wide ranging, affecting people's health, wealth, and relationships. Those harmed by gambling have markedly poorer health and wellbeing, with the wellbeing scores of problem gamblers estimated to be similar to those who are unemployed or in very bad health.4Forrest D The unhappiness of problem gamblers. Asia Pacific Conference.http://journal.gamblingstudies.org/index.php/apcg/article/download/2/3Date: 2012Date accessed: December 8, 2020Google Scholar Few countries have estimated the scale of gambling harms. Those countries that have (eg, Australia and New Zealand) estimate that harms from gambling are of a similar magnitude to major depressive disorder or moderate alcohol misuse or dependence.5Browne M Langham E Rawat V et al.Assessing gambling-related harm in Victoria: a public health perspective. Victorian Responsible Gambling Foundation, Melbourne2016Google Scholar In some jurisdictions, there is increasing recognition of gambling as a public health issue requiring greater focus on universal preventive measures to address the harms it generates.6New Zealand Ministry of HealthStrategy to prevent and minimise gambling-related harm 2016/17 to 2018/19. Ministry of Health, Wellington2016Google Scholar There is also recognition of the interrelation between gambling and other health issues, including mental health, substance misuse, and suicidality, with gambling contributing as both a cause and consequence.7Cowlishaw S Kessler D Problem gambling in the UK: implications for health, psychosocial adjustment and health care utilization.Eur Addict Res. 2016; 22: 90-98Crossref PubMed Scopus (56) Google Scholar For most of the latter part of the 20th century, gambling has been overlooked as a public health issue. Gambling harms are hidden and often complicated by associations with other health difficulties. Unlike alcohol, there are few diseases to which the impact of gambling engagement can be unilaterally attributed. This has served to mask the health harms associated with gambling, and to shield gambling as a public health issue from the view of regulators, legislators, and public health specialists alike. In some jurisdictions, such as the UK, the catalyst for change has been agitation from increasingly well organised and effective campaigning organisations that represent those with lived experience of gambling harms. These groups have been powerful in drawing attention to the health harms of gambling but also represent an unsettling reality that the public health community itself has been found wanting in drawing attention to these issues. Pathological gambling was already recognised as a mental and behavioural disorder in the WHO International Classification of Diseases, Tenth Revision (ICD-10) and is included in the ICD-11 as gambling disorder (6C50), with a new category of gaming disorder (6C51) added to accompany it.8WHOInternational statistical classification of diseases and related health problems.11th edition. World Health Ogranization, Geneva2019Google Scholar These two disorders are within the larger category of disorders due to addictive behaviours, yet the scale and impact of gambling upon health and wellbeing remains a largely neglected topic of inquiry. Information and evidence on early identification and management of problem gambling and gambling and gaming disorders is also largely lacking. Looking globally, regulators and legislators have struggled to keep pace with the rapid development of the commercial gambling industry. There are wide variations in what forms of gambling are legally permitted in different jurisdictions and an equally broad number of economic models for the provision of commercial gambling—which in turn, feeds into wide variations in the range and scope of regulatory models. As observed with other health harming industries, there is also a clear pattern whereby increased regulation or perceived market penetration in some jurisdictions encourages greater attention on low-income and middle-income countries as the next opportunity for commercial gambling markets.9Reith G Wardle H Gilmore I Gambling harm: a global problem requiring global solutions.Lancet. 2019; 394: 1212-1214Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar African nations, for example, have been viewed as large growth market, with many nations having strong sporting cultures, rapidly growing mobile phone ownership, and penetration and technology companies aiming to provide bespoke solutions to increase the speed with which payments can be processed. Online gambling and its marketing remain poorly regulated in many nations and the risks posed by expanding commercial gambling, and specifically online gambling, are high, especially due to the lack of support mechanisms for those most impacted by gambling harms. The COVID-19 pandemic has created unprecedented restrictions on people's movements. The cancellation of major sporting events and the closure of commercial and social venues altered the gambling landscape during this time. Many jurisdictions are now examining the long-term impact of COVID-19 upon gambling behaviours and industry responses to this. In the UK, the gambling regulator has described COVID-19 as accelerating key trends,10Gambling CommissionCEO breakfast briefing—Neil McArthur.https://www.gamblingcommission.gov.uk/news-action-and-statistics/Media-resources/Speech-web-pages/CEO-Breakfast-briefing-Neil-McArthur-November-2020.aspxDate: November, 2020Date accessed: December 12, 2020Google Scholar such as the growth of online gambling and increased interest in certain products, such as esports. It is against this backdrop that The Lancet Public Health Commission on gambling has been established. By assembling world leaders in public health, mental health, policy, and gambling studies, and supported by an advisory group that will include those with lived experience, the Commission aims to thoroughly consider the global issues related to gambling. The Commission will focus on the political and corporate determinants of harm, the epidemiology of gambling harms, including examining inequalities, interventions to reduce harms, and critical appraisal of regulatory, political, and public health responses to gambling. The ultimate goal of the Commission is to set a progressive agenda to guide action to reduce population-level gambling harms, to protect people from these harms, and to provide evidence-based care when needed. To inform the work of the Commission, The Lancet Public Health would welcome submissions on these topics. With rapid change in how gambling is promoted and provided, and the fast pace of change evident among gambling industries, it is vital to support the impetus for change to address and prevent gambling harms. HW reports personal fees from the Advisory Board for Safer Gambling, outside the submitted work, and in the last 3 years has worked on a project funded by GambleAware. HW runs a research consultancy, providing research services to public and third sector bodies. HW does not and has not provided consultancy services for the gambling industry. LD reports grants from Indivior and Seqirus, outside the submitted work. All other authors declare no competing interests. HW, LD, and SS are co-chairs of The Lancet Public Health Commission on gambling. Gambling among adolescents: an emerging public health problemWhile gambling among adults has been rightly identified as an urgent, understudied, and neglected public health issue, child health and wellbeing can also be harmed by this behaviour. In 2019, 11% of 11–16 year olds in the UK said they had spent money on gambling activities in the previous 7 days, and 36% reported doing so in the preceding 12 months. While these figures have remained static over recent years, two deeply concerning trends are beginning to emerge. Full-Text PDF Open Access