Gambling and health

Updated: 4 days ago

Publicly the industry denied and continues to deny the significance of gambling harm on a population level. This refusal to accept the reality is compounded by the industry's lack of funding in public health research, despite the WHO commenting on the need to prioritise gambling-harm on agendas due to the magnitude of harm from gambling being comparable to the harm accrued by alcohol-use disorder or major depressive disorder.


Harms in affected others challenge the industry in two ways. First, measures to raise awareness and prevent gambling harms in individuals who do not gamble will reduce the appeal of gambling and contribute to its social unacceptability. Second, the 'freedom to gamble' argument is confounded if individuals who do not gamble are harmed.


The industry has largely refused to acknowledge the significance of harms in affected others, individuals who gamble and suffer low-risk harms, moderate-risk harms, and legacy harms due to previous gambling. This situation has not been helped by the chronic underfunding and lack of independence in research, education, and treatment.


Summary

“The gambling-related burden of harm appears to be of similar magnitude to harm attributed to major depressive disorder and alcohol misuse and dependence. It is substantially higher than harm attributed to drug dependence disorder.”


WHO: The epidemiology and impact of gambling disorder and other gambling-related harm 2017 1


Gambling addiction was first formally recognised as a mental disorder by professionals in the US through the Diagnostic and Statistical Manual of Mental Disorders-III in 1980. Over the past two decades, gambling harm has emerged as a pressing public health issue globally. Domestic and international studies have reported statistical links between gambling harm in adults and suicide, mortality, and poor health. When faced with evidence of the links of gambling and harm to health, industry lobbyists have commonly steered away from admitting any responsibility; instead, they have promised research, reform, or reiterated commitments to safer gambling standards. Moreover, the industry has worked to associate itself with the NHS and other health organisations.


Gambling harm may be experienced by individuals that gamble, affected others of people who gamble, and by communities. Research from Australia in 2016 reported a taxonomy of harms over eight domains: financial, relationship, emotional, health, cultural, work or study, criminal activity, life course and intergenerational harms.


Responsible gambling mantras have largely replaced public health messaging in Great Britain. Meanwhile, ideas of risk-free gambling and safer gambling have been furthered. Current safer gambling ads seldom reflect the significance of gambling harm, especially on affected others, due to them being industry-supported. Similarly, specialist treatment options and awareness among health care workers remain challenges and are limited by such efforts being primarily managed with voluntary donations.


Moreover, public health research in New Zealand and Australia have explored the significance of gambling harm on quality of life by reporting disability weights. These disability weights allow researchers and public health stakeholders to understand the significance of gambling harm on the individual and the population through comparison to other health states. Based on this research, a WHO report found an "urgent need to place gambling on national and international public health agendas", among other things.


At the time of writing, little is known about the significance of harm in young people, individuals who previously gambled, and former affected others (legacy harm). Whereas gambling-harm has featured in Australia's Monash guidelines for healthcare professionals for over a decade, the UK's National Institute for Health and Care Excellence (NICE) is yet to begin reviewing the evidence on gambling harm.


What is known?


Taxonomy of gambling harm

  • Gambling-harm can manifest both in individuals that gamble and individuals that are affected by other people’s gambling, as general, crisis, and legacy harms, across the domains of 2

  • Financial harm

  • Relationship disruption, conflict or breakdown

  • Emotional or Psychological Distress

  • Decrements to Health

  • Cultural Harm

  • Reduced Performance at Work or Study

  • Criminal Activity

  • Lifecourse and Intergenerational Harms

Prevalence of harms in Family Member's affected by gambling disorder (Affected Others) 3

  • 93% reported that their loved one's disordered gambling impacted their financial security (64% stating that the impact was significant)

  • 89% reported a reduction in available spending money and a 88% reduction in savings

  • 23% reported losing a major asset such as a car, home, or business, and 12% had become bankrupt

  • 82% reported that their loved one's disordered gambling impacted their work and/or education (37% stating that the impact was significant)

  • 76% reported reduced performance at work or study due to tiredness or distraction

  • 55% and 50% reported being late and absent, respectively

  • 99% reported that their loved one's gambling compulsion had harmed their health (46% stating that the impact was significant, 38% moderate, 15% slight)

  • 95% reported loss of sleep due to stress or worry

  • 64% reported reduced physical activity, 30% increased alcohol use, 33% increased tobacco consumption, 56% eating too much, and 44% eating too little

  • 29% reported neglecting their medical needs, 36% reported increased use of health services, and 21% reported requiring emergency treatment for health issues caused or exacerbated by their loved one's gambling

  • 16% reported committing acts of self-harm, and 8% had attempted suicide

  • 96% reported experiencing relationship harms (67% stating that the impact was significant)

  • 89% and 82% reported greater tension and conflict, respectively

  • 71% reported feeling excluded from others

  • 68% reported threatening separation or ending the relationship

  • 33% reported separating or ending the relationship with the family member who gambles and potentially related others

  • Other harms

  • 21% reported incidents of violence

  • 21% reported feelings of shame within their religious or cultural community

  • 7% reported engaging in petty theft or dishonesty as a consequence of their family member's gambling

  • Other addictions

  • Family members of individuals with gambling disorder reported elevated rates of problematic use of substances

  • Alcohol: 34.6%

  • Drugs: 21.2%

  • Legal highs: 3.2%

  • Prescription drugs: 5.0%

Severity of gambling-harm on quality of life in Adults 4.5

Disability Weights (where 0 = perfect health and 1 = death)

  • Schizophrenia: acute state: 0.76

  • Heroin and other opioid dependence: 0.64

  • Gambling disorder harm (PGSI 8 or more): 0.54 (NZ 18)

  • Manic episode of Bipolar Disorder: 0.48

  • Gambling disorder harm (PGSI 8 or more): 0.44 (AUS 17)

  • Migraine: 0.43

  • Moderate alcohol use disorder: 0.39

  • Moderate-risk harm gambling (PGSI 2-7): 0.37 (NZ 18)

  • Affected others at gambling disorder harms: 0.36 (AUS 17)

  • Affected others at moderate-risk harms: 0.33 (AUS 17)

  • Stroke: long-term consequences, moderate plus cognition problems: 0.31

  • Moderate-risk harm gambling (PGSI 2-7): 0.29 (AUS 17)

  • Mild alcohol use disorder: 0.26

  • Low-risk harm gambling (PGSI 1-2): 0.18 (NZ 18)

  • Urinary incontinence: 0.15

  • Affected others at low-risk harms: 0.17 (AUS 17)

  • Low-risk harm gambling (PGSI 1-2): 0.13 (AUS 17)

  • Hearing loss: complete, with ringing: 0.09

Significance of gambling-harm on the population in Years of Life Lost due to Disability (YLD)

  • New Zealand (Adult population: 3.6m) 6

  • Combined total of years lost with gambling-harm related quality of life effects in the New Zealand Adult population: 162, 000 years

  • Anxiety and depressive disorders: 106, 000 years

  • Harms from someone else's gambling in adults: 94, 700 years (prevalence: 13.6%)

  • Alcohol – Hazardous drinking (>8 AUDIT): 87, 600 years

  • Harms from own gambling in adults: 67, 200 years (prevalence: 7.3%)

  • Diabetes: 26, 000 years

  • Drug use disorders: 22, 400 years

  • Stroke: 12, 900 years

  • Eating disorders: 3, 980 years

  • Victoria, Australia (Adult population 4.4m) 7

  • Major depressive disorder: 148, 000 years

  • Alcohol use and dependence: 148, 000 years

  • Combined total of years lost with gambling-harm related quality of life effects in the Victorian Adult population: 118, 000 years

  • Harms from own gambling in adults: 102, 000 years (past-year prevalence: 12.5%)

  • Diabetes Mellitus: 22, 700 years

  • Harms from someone else's gambling in adults: 16, 300 years (past-year prevalence: 2.8%)

  • Cannabis dependence: 5, 780

Significance of gambling-harm on the population in Years of Life Lost due to Mortality (YLL)

  • Research from the UK involving bank data from over 100, 000 customers found that high levels of gambling were associated with a 37% increase in mortality 8

  • The last Adult Psychiatry Morbidity Survey 2007 that considered gambling-harm reported that individuals with gambling disorder were more likely to have thoughts about suicide (19.2% vs 4.1%) and to have made a suicidal attempt in the past year (4.7% vs 0.6%) compared to individuals who do not suffer gambling-harm. 9

  • A study of 16-24 year olds living in Great Britain found that Men and Women who indicated gambling disorder harms were 9.0 and 4.9 times more likely to attempt suicide, after adjusting for anxiety, impulsivity, life satisfaction, and other factors 10

  • Standardised mortality ratios 11

  • Men and Women in Sweden, aged 20-49 year olds and diagnosed with GD, were 19.3 times more likely to suffer from suicide when compared to the general Swedish population of the same ages

  • Men and Women in Sweden, aged 20-49 years old and diagnosed with GD, were 6.2 more likely to suffer from any mortality when compared to the general Swedish population of the same ages

What the industry said?


Michael Dugher, CEO of the Betting Gaming Council 12

"The UK's addiction rate stands at 0.5% of the adult population, which is low compared to the international standard. The rates have also remained 'broadly steady around or below one percent for the past 20 years."


Dugher frames the topic of gambling harm on the segment of adults suffering the most severe harms due to gambling in the past 12 months while omitting the experiences of affected others, individuals who previously had gambled, and individuals experiencing subclinical levels of gambling harm. Moreover, there are significant concerns with measuring gambling harm using self-completion forms included in health surveys, and as such, the stated 0.5% is expected to be a significant underestimate.


The industry rarely comments on affected others as it recognises that this is likely to be the most damaging to their public relations strategies. Instead, the industry benefits from the fallacious societal stigma that gambling addiction is the individual's fault; however, the same cannot be easily argued for loved ones, especially the children who suffer harm.


Gambling Commission in a briefing paper for Local Authorities and local Public Health providers February 2018 13


“The numbers of those who experience harm as a result of gambling by others will be considerably greater than the number of people who harm themselves.”


“These are not small numbers. They suggest a significant public health issue which has received remarkably little attention relative to other population level concerns.”


The Gambling Commission makes clear why gambling harm should be considered as a public health issue. Identifying gambling as a significant public health issue is in direct contrast to how the Gambling Commission falls under the remit of the Department of Culture, Media and Sport (DCMS) instead of the Department of Health and Social Care.


Michael Dugher, CEO of the Betting Gaming Council 14


“NHS Charities said it wouldn't be possible for betting co's to make a direct donation, but they were happy for us to donate all the profits from this special fun virtual Grand National to help the NHS at this difficult time. Most people agree there's nothing wrong with this...”


Dugher states that NHS Charities were not accepting a direct donation from the gambling industry. This quote demonstrates the BGC’s interest in associating with the NHS for the 4.8m viewers who tuned in to watch this virtual horse race which raised £2.6m. 15


“You don’t have to bet. If you don’t want to have a bet, please make a donation direct to NHS Charities. But millions of people do enjoy an occasional flutter & do so responsibly & safely.”


Dugher argues that millions of people enjoy an occasional flutter while ignoring the millions that suffer gambling harm and the individuals who gamble frequently and make up significant amounts of the industry’s profit.


Betting and Gaming Council 16


“Suicide is a complex issue and the examination of any links to gambling or disordered gambling requires great care and sensitivity. We suggest that a collaborative and careful approach to understanding linkages is required. The aim of research should be to explore what is clearly a difficult subject and provide pragmatic solutions.”


The BGC creates an aura of doubt around gambling-suicide, despite evidence from studies across the world reflecting that individuals with gambling-disorder are many times more likely to suffer from suicidal harm.


“Through continued funding by our industry over more than 20 years, these charitable services are able to provide free of charge treatment, support & advice services for anyone affected by gambling.”


The BGC boasts of their voluntary funding for treatment services for harms caused by their industry. Thus, the industry demonstrates that treatment services are available due to the industry's generosity while ignoring issues with treatment access, awareness, and chronic underfunding.


Mark Etches, CEO of GambleAware 17


[Britain was] “in great danger of sleepwalking into a future public health storm over gambling-related harm”.


Etches reflects on the numbers of 11–16 year olds with a gambling disorder and signifies concern for the future. Contrastingly earlier that year, evidence reported on by the World Health Organisation (WHO) reflected a worryingly significant ongoing neglected public health crisis with an “urgent need to place gambling on national and international public health agendas”. 1


References

1. Abbott M. The epidemiology and impact of gambling disorder and other gambling-related harm. Geneva: World Health Organization; 2017. Available from: https://www.who.int/docs/default-source/substance-use/the-epidemiology-and-impact-of-gambling-disorder-and-other-gambling-relate-harm.pdf?sfvrsn=5901c849_2 [Accessed: 25th March 2020]

2. Langham E, Thorne H, Browne M, Donaldson P, Rose J, Rockloff M. Understanding gambling related harm: A proposed definition, conceptual framework, and taxonomy of harms. BMC Public Health. 2016;16(1): 80. Available from: doi:10.1186/s12889-016-2747-0

3. Banks J, Andersson C, Best D, Edwards M, Waters J. Families Living with Problem Gambling: Impacts, Coping Strategies and Help-Seeking. 2018. Available from: https://about.gambleaware.org/ [Accessed: 13th March 2021]

4. Rawat V, Browne M, Bellringer M, Greer N, Kolandai-Matchett K, Rockloff M, et al. A tale of two countries: comparing disability weights for gambling problems in New Zealand and Australia. Quality of Life Research. 2018;27(9): 2361–2371. Available from: doi:10.1007/s11136-018-1882-8

5. Rawat V, Greer N, Langham E, Rockloff M, Hanley C. What is the harm? Applying a public health methodology to measure the impact of gambling problems and harm on quality of life. Journal of Gambling Issues. 2017;36(36). Available from: doi:10.4309/jgi.2017.36.2

6. Browne M, Bellringer M, Greer N, Kolandai-Matchett K, Rawat V, Langham E, et al. Measuring the Burden of Gambling Harm in New Zealand. Central Queensland University and Auckland University of Technology. 2017.

7. Browne M, Langham E, Rawat V, Greer N, Li E, Rose J. Assessing gambling-related harm in Victoria: a public health perspective. Victorian Responsible Gambling Foundation. 2016.

8. Muggleton N, Parpart P, Newall P, Leake D, Gathergood J, Stewart N. The association between gambling and financial, social and health outcomes in big financial data. Nature Human Behaviour. 2021;5(3): 319–326. Available from: doi:10.1038/s41562-020-01045-w [Accessed: 22nd March 2021]

9. Wardle H, Dymond S, John A, McManus S. Problem gambling and suicidal thoughts, suicide attempts and non-suicidal self-harm in England: evidence from the Adult Psychiatric Morbidity Survey 2007. Gambling Commission. 2019.

10. Wardle H, McManus S. Suicidality and gambling among young adults in Great Britain: results from a cross-sectional online survey. The Lancet Public Health. 2021;6(1): e39–e49. Available from: doi:10.1016/S2468-2667(20)30232-2

11. Karlsson A, Håkansson A. Gambling disorder, increased mortality, suicidality, and associated comorbidity: A longitudinal nationwide register study. Journal of Behavioral Addictions. 2018;7(4): 1091–1099. Available from: doi:10.1556/2006.7.2018.112

12. Michael Dugher. It’s important that the Gambling Review tackles betting by under-18s – but let’s deal in facts, not fiction. Available from: https://www.politicshome.com/members/article/michael-dugher-its-important-that-the-gambling-review-tackles-betting-by-under18s-but-lets-deal-in-facts-not-fiction [Accessed: 28th March 2021]

13. Gambling Commission. Gambling-related harm as a public health issue. 2018. Available from: https://www.gamblingcommission.gov.uk/PDF/Gambling-related-harm-as-a-public-health-issue.pdf [Accessed: 1st February 2021]

14. @MichaelDugher. ‘1. NHS Charities said it wouldn’t be possible for betting co’s to make a direct donation, but they were happy for us to donate all the profits from this special fun virtual Grand National to help the NHS at this difficult time. Most people agree there’s nothing wrong with this...’. [cited 2020 April 3.] Available from: https://twitter.com/MichaelDugher/status/1246177242939559944 [Accessed: 28th March 2021]

15. BBC Sport. Virtual Grand National raises £2.6m for NHS Charities Together. BBC Sport. 5 April 2020. Available from: https://www.bbc.co.uk/sport/horse-racing/52175385 [Accessed: 29th March 2021]

16. UK Parliament – Betting and Gaming Council. Betting and Gaming Council – Written evidence (GAM0068). 2019. Available from: https://committees.parliament.uk/writtenevidence/154/html/ [Accessed: 29th March 2021]

17. Davies R. 25,000 children in Britain are problem gamblers, report finds. The Guardian. 12 December 2017. Available from: https://www.theguardian.com/society/2017/dec/12/children-britain-problem-gamblers-report [Accessed: 29th March 2021]