Introduction
The development of modern public health models began nearly 200 years ago. This health service paradigm has significantly shaped how we prevent, prepare for, and treat human health conditions at an individual and population level. Gambling-related harms, however, have not garnered the same level of attention from these health service models as other acute and chronic health conditions. Despite these circumstances, the resources, knowledge, and skill sets embedded in public health systems and models may offer substantial benefits for addressing gambling harms.
Gambling harms constitute a serious public health issue. Worldwide, an estimated 0.1% to 5.8% of adult populations experience serious problems with gambling (Calado and Griffiths
2016). Although the health, economic, social, and personal harms of gambling are most severe among problem gamblers, they can extend across the risk spectrum (Blaszczynski
2009; Browne et al.
2016; Langham et al.
2016). Further, the impact of these harms affects not only the gambler, but also radiates with negative implications for family, friends, workplaces, and communities (Langham et al.
2016). Though much of the research and policy interest in gambling has focused on prevalence rates and downstream treatment of people with acute gambling problems (Productivity Commission
2010), interest in harm prevention from a public health perspective is growing (Browne et al.
2016; Wardle et al.
2019).
This paper presents a critical review on the evolution of the public health perspective on gambling harms, at a high level. It also considers how a public health model can be operationalized to address gambling harms, though it acknowledges that differences across jurisdictions and local contexts can affect public health implementation efforts. Generally, the authors hope that this paper will prompt discussion and debate concerning how this approach can contribute to a growing evidence base and catalyze the development of policies attending to gambling-related harm at a population health level.
Discussion
Successful public health interventions take into account local settings. Gambling presents unique social, economic, political, regulatory, and technological contexts that vary by jurisdiction and deserve consideration in the design of public health approaches to harm prevention and minimization. For instance, the mix and design of some gambling products in a jurisdiction can influence patterns of consumption (Schull
2014). Two decades ago McMillen (
2000) observed, and predicted, that global and digital technological advances related to online gambling would be a significant context and challenge for regulatory development, enforcement, and effective harm minimization strategies. In New Zealand, Adams and Rossen (
2012) point out that institutional processes and policies can compromise a public health approach to gambling, and highlight the need to consider vested interests in design and development. In comparison with other public health issues (e.g., obesity, physical activity, alcohol policy, tobacco control, blood-borne viruses, and sexual health), Livingstone et al. (
2019) conclude that public health interventions for gambling should rely on the best available evidence and must be plausible. With these points in mind, there are two foundational pillars to addressing gambling-related harm from a public health perspective:
making a case for gambling as a public health issue and
the development of robust measures that align with a disease model (Browne et al.
2017c).
While gambling harm may be perceived by public officials and policy actors as a
public health issue, it is rare that it is institutionally operationalized and addressed by public health systems. One indicator of this phenomenon is the governance structure of legal gambling industries, which often feature ministries of finance, justice, or consumer affairs as their principal government authorities, and typically not ministries of health (Gambling Commission
2019; Kennedy
2019; Thompson
2019). These governing arrangements have the effect of excluding public health actors and departments from gambling-related policy development until gambling harm becomes viewed as a public crisis requiring immediate public health input. At present, New Zealand is the only country with a public health approach embedded in the Gambling Act. No others have followed, even though public health principles to approaching gambling were advanced almost two decades ago in other countries (Government of New Zealand
2003; Korn et al.
2003; Shaffer
2003) In recent years, the growing regulatory pressure and public interest surrounding gambling harm in Great Britain stands out as a notable case study (Davies
2017; Gambling Commission
2018; Kollewe
2019; British Broadcasting Corporation
2020). In response, a harm reduction strategy is now incorporated at the policy level in the Gambling Commission’s
National Strategy to Reduce Gambling Harms (Gambling Commission
2019).
Solid epidemiologic evidence, in particular, is critical to fostering practical and policy-level changes in the field of gambling harm prevention and reduction. At the international level, Vladimir Poznyak, Coordinator of the World Health Organization Management of Substance Abuse program, points out that identifying significant impacts on health across the full spectrum of gambling behaviour is necessary to advance the public health agenda. This has also been noted in foundational documents across the decades including Korn and Shaffer’s public health framework (1999), the Australian Productivity Commission’s public health policy model (
2010), and the more recent frameworks advanced in the Conceptual Framework of Gambling Harm (Abbott et al.
2018), the
Assessing Gambling-Related Harm in Victoria study (Browne et al.
2016), and the Framework for Action in Great Britain (Wardle et al.
2018). Encouraging public health system involvement to leverage expertise and resources for preventive interventions—not just health promotional information—and data development and analysis represent key opportunities for the field’s advancement. Moreover, having consistent standards of harm minimization will enhance adoption, with international partnerships fulfilling a key role.
Population-level longitudinal studies have contributed to tracking risk factors, the etiology of problem gambling, and movement into and out of gambling risk categories over time. This practice contributes to population health assessment that serves the needs of evidence-informed policy and program development. Still, there are only six jurisdictions internationally in which these studies have taken place. More prospective longitudinal research with consistent, validated gambling harm measures across study jurisdictions is needed to clearly identify priority harms and population subgroups that are most vulnerable to negative outcomes. The inclusion of harm-specific measures such as the PPGM and the newer SGHS would build on the earlier Canadian and Massachusetts prospective studies that assessed gambling harm prevalence. In the interest of transparency, cross-jurisdictional support, and encouraging more research from a public health perspective, expanded longitudinal research would present an opportunity to share data widely among the gambling and public health research communities and help advance knowledge from multiple disciplinary perspectives. It would also help to fill the research gap identified by
The Lancet (
2017) where gambling and public health policy is concerned.
Beyond health assessment data, health surveillance data can enable monitoring and evaluation of immediate indicators of gambling risk and harm (e.g., the expansion of high-risk betting events or self-exclusions associated with new products). Although there is growing interest in integrated forms of gambling-related harm data showing gambling behaviour, treatment and counselling interactions (including third-party interactions), related bankruptcy filings, or credit counselling, much more work is needed to develop these systems. Again, the development of integrated health information systems is an area where public health systems have some expertise and knowledge to offer (Luić and Striber-Devaja
2006; Shah and Rogers
2019).
Another key challenge and opportunity relates to measurement tools. Proxy measures of harm often used in population surveys, such as the Problem Gambling Severity Index (PGSI) (Ferris and Wynne
2001), are useful for determining risk categories but have shortcomings in terms of measuring harm as an outcome (Langham et al.
2016). As mentioned earlier, the Problem and Pathological Gambling Measure (PPGM) (Williams and Volberg
2010) is an instrument used by some researchers to identify the incidence of specific gambling harms. An advantage of the PPGM is that it allows concurrent assessment of problem gambling and gambling-related harm, but a disadvantage is that it fails to capture the extent of harm being experienced by close relations. The more recent frameworks developed in Australia, including the harms taxonomy (Browne et al.
2016), and in Great Britain (Wardle et al.
2018) help to conceptualize what questions need to be asked, of whom, and in what context.
Researchers in Australia and New Zealand have done much to advance the public health agenda by using health-related quality of life measures, including burden of disease, to situate gambling risk levels relative to other health conditions (Adams and Rossen
2012; Browne et al.
2016,
2017a). Using data from the
Assessing Gambling-Related Harm in Victoria: A Public Health Perspective study, the authors created a taxonomy that can be used as a checklist of harms at the individual, family, and community levels. This 72-item list of harms was subsequently shortened to a 10-item Short Gambling Harm Screen (SGHS). The abbreviated measure, featuring an exceptionally high correlation score (
rs = .94), is effective at capturing gambling-related harm at a level almost as high as the original 72-item checklist (Browne et al.
2018). As such, the SGHS presents a new opportunity for measurement that addresses gambling harm directly in a way that would have a relatively low participant burden.
Even so, the SGHS is not without critique. Some of the items in the SGHS may be perceived as trivial or inconsequential (e.g., being less able to spend money on other recreational activities), and perhaps represent an opportunity cost rather than a harm from gambling (Delfabbro and King
2019). Still, the high correlation between the SGHS and the 72-item checklist suggests that despite the potential of some items to be framed as an opportunity cost, they still capture perceived harm among people who gamble. Research using this technique consistently indicates that a larger proportion of the total burden of harm is associated with low-risk and moderate-risk gamblers (Browne et al.
2016,
2017c). Although the harms experienced by this group may not be as severe as those with problem gambling, by virtue of their greater numbers they are responsible for more harm at the population level. The high proportion of harms experienced by lower-risk categories aligns with the “prevention paradox”, which has been observed for other public health issues where prevention strategies are directed towards the small group at high-risk rather than the many others in low-risk categories (Browne et al.
2018; Delfabbro and King
2019; Rose
1981). The prevention paradox can be applied to gambling for the majority of harm categories, with some exceptions for rare and severe harms (Bourget et al.
2003; Canale et al.
2016; Browne and Rockloff
2018). In contrast, some critiques of the prevention paradox have argued that the misclassification of low-risk gamblers, scoring systems that under-represent the frequency of harms among high-risk groups, and conflation of behaviour as harm have not been adequately addressed (Delfabbro and King
2017,
2020).
The attribution of harms to gambling also continues to be an ongoing challenge. Gambling problems stem from complex and diverse social and economic factors (Abbott et al.
2018), and may be complicated by the high rate of comorbid health conditions. Up to 94% of people with gambling problems will have at least one cooccurring mental health or addiction disorder (Yakovenko and Hodgins
2018), with alcohol and nicotine dependence, depression, anxiety, and obsessive-compulsive disorder heavily represented (Crockford and el-Guebaly
1998; Lorains et al.
2011; Yakovenko and Hodgins
2018). It is likely that some gambling-related harms result from or are worsened by a combination of mental health and addiction disorders, yet fewer than one-fifth of people with gambling problems and psychiatric disorders are treated for these conditions concurrently (Browne and Rockloff
2018; Yakovenko and Hodgins
2018). Therefore, there is an opportunity for health professionals to screen for gambling problems when people present with mental health and substance use disorders. It may be that by treating the gambling problem, there will be a positive impact on comorbid conditions, or vice versa. Evidence further suggests that situating mental and behavioural disorders as an integral component of public health, from prevention through recovery, can lead to reduced health care costs overall and enhance recovery potential (Chen et al.
2018).
A pragmatic approach to measuring gambling-related harm could be to use measurement tools both within and outside the gambling sector. For example, Sweden tracks helpline call data as a rough measurement of harm experienced by gamblers and significant others. There have also been calls for financial institutions to monitor gambling transactions, as well as other sectors such as intimate partner violence services (where gambling is listed as a cause), bankruptcy courts, and coroners’ reports where gambling is indicated as a cause of suicide (as is done, for example, in Quebec, Canada (Bourget et al.
2003) and Hong Kong (Papaioannou et al.
2010)). Although it may be more challenging to draw upon diverse sectors and data sources to assess gambling-related harm, it also creates the opportunity to develop an integrated, or “syndemic”, network of stakeholders that could work towards a common public health goal to identify gambling problems at earlier stages and respond in a concerted manner to reduce or prevent harm from occurring (Nower and Caler
2018). This would involve building coalitions of key stakeholders and applying a public health lens to areas where people are most likely to suffer harm, and developing a regularly updated set of indicators drawn from credible and reliable sources. The importance of a base of foundational evidence is a key principle underlying a public health approach to gambling, as was noted by Shaffer in 2003 and is currently demonstrated by the Kupe data explorer supported by the New Zealand Health Promotion Agency.
Conclusion
Gambling is a globally prevalent activity engaged in by the majority of populations. It generates hundreds of billions of dollars annually for industry and governments (Casino.org
2016). However, for a large number of people and their close relations, gambling is associated with the experience of significant risk and harm (Calado and Griffiths
2016). As such, gambling harm can be considered a serious population and public health issue. Initial efforts to adopt a public health approach began in the 1990s following the New Zealand and Australia population surveys and have not yet been fully realized beyond New Zealand. To date, gambling harm has received most of its attention from downstream medical models, as evidenced by the contributions and emphasis of treatment and research professionals from the fields of psychology (Baxter et al.
2019). While this disciplinary orientation is vital to addressing risk and harms associated with gambling, upstream prevention at the population level requires further development.
Over the past few decades, momentum has been building to a public health approach that could address this need for upstream prevention of gambling-related harms. With recent and emerging developments in the areas of research, practice frameworks, and measurement tools, opportunities to integrate and operationalize public health approaches to gambling harm prevention appear more viable than ever. The early foundation of guiding principles, prospective studies, new frameworks, and advances in understanding the reach of gambling harm provide support to a public health approach.
When comparing developments in the gambling harm prevention and reduction field to the functions of modern public health systems, there is evidence of alignment and opportunities for further development and collaboration. For instance, safer gambling initiatives reflecting health promotion are well developed. Regulatory frameworks and preventive initiatives such as youth education and risk screening also reflect elements of health protection and harm prevention. To a lesser degree, health assessment and surveillance have featured contributions such as various prevalence studies and limited use of behavioural data from online operators. The Kupe data explorer (Health Promotion Agency
2018) provides an example of how data can be presented for rapid access to gambling and health information.
Moving forward, making the case that gambling harm is a public health issue and developing data to articulate the issue are the biggest challenges and opportunities for the field. Public health policymakers and practitioners can make meaningful contributions to the goal of gambling harm prevention by engaging on these two points and collaborating with those already working in the field. Areas where gambling harm intersects with other public health issues such as substance abuse, mental illness, poverty, and so on, can form a basis for developing integrated approaches to complex population health problems. A substantial evidence base that began in the 1990s on gambling and mental health comorbidities supports the need to take these factors into consideration. Prospective longitudinal studies have been pivotal in establishing a public health approach. They have demonstrated the movement between risk categories, and that prevention and intervention points could be addressed more thoroughly. New longitudinal studies with a consistent definition and measures of gambling harm are needed across jurisdictions.
Like tobacco and alcohol consumption, gambling is a complex policy issue with inherent cultural, social, and economic values that make addressing associated harms difficult to solve. While the public health approach may not provide a definitive solution to harm prevention, there are many indications it can help improve the current state of population health.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.