Note on reducing gambling harm and a public health approach to this

Note on reducing gambling harm and a public health approach to this

Gambling harm is going up lots of radars now. The UK Govt has been reviewing the existing Gambling Act and the result of that is expected to be published shortly.

This has been a rather turbulent beast to tame. It is out there to be 1) used by any who want to use it to frame evidence or arguments. I would be interested in your views. 

 

1.       Framing gambling

It isn’t a “harmless leisure pursuit”.

The question of how gambling is framed matters to the response. Many frame it as “a public health issue”. What that means requires careful definition. Will come back to)

For more than 20 years, UK Government policy has portrayed gambling as, firstly, enjoyable; secondly, an expression of adult freedom; and, lastly, harmful only to a minority. The UK Government and policy makers have employed discourses that align more closely with those of the gambling industry than with those of the individuals, families, and communities affected by the harms of gambling

The narrative has been dominated by individualised & often pathologised understandings that serve to maintain the status quo and hide broader societal perspectives, such as the harmful effects of gambling products and gambling environments.

This involves portraying any harms caused by their products as limited to an atypical minority, rejecting upstream determinants of harm.

Governments across the world have primarily focused on individualised behavioural addiction frameworks. There is a strong pull towards helping identifiable individuals ar risk or with identified need. Not wrong, simply just not by itself sufficient. Definitely shouldn’t be at the expense of upstream determinants of risk and addressing the social, commercial or economic context.

 

2.       Gambling causes harm.

I haven’t here made an effort to quantify the harm. The PHE review did do that. In summary. estimates of ‘problem’ gambling rates vary between 0.5% and 0.9%, with between 5-6% of people considered ‘at risk’ (this does not include all those experiencing harm). 

According to small Ipsos Mori poll (2015) around 0.6% of children  460k 11-15 yr old gamblers with 55k addicted (it is illegal till the age of 18). 

NB readers should take numbers with caveats. Many are based on small sample surveys and may be prone to biases. All the statistical and epi issues readers will have learned interpreting (or misinterpreting) survey data through covid also apply in many other spaces.  

Characterising the harm

Gambling harm is complex, difficult to pin down exactly and can span financial and debt, relationship, addiction, mental illness and suicide. There are diverse impacts on individual and community health and wellbeing – from financial and material loss, to relationship breakdown,   abusive relationships, neglect of others, debt / poverty, crime and suicide. The harms of gambling are inherently interconnected with many comorbid health issues – including those affecting mental health (suicide, depression and anxiety, personality and bipolar disorder), and dependence on substances such as alcohol, drugs and tobacco.

 

Financial harm.

A study by the University of Liverpool and the National Centre for Social Research found that gambling firms make the vast majority (at least 70%) of their money from the 5% of accounts that with the biggest losses.

Gamblers from the poorest areas were more likely to lose money in online casinos, with a risk of high-intensity play; and more likely to have lost their money using virtual slot machines – a product with a high rate of addiction. Online gambling activity is not subject to the same level of regulation as land-based gambling.

Recent Oxford and Warwick  research highlights the impact of gambling on individuals’ health and quality of life. There was a statistically significant correlation between gambling and declining health, opportunity and quality of life outcomes – with harm rapidly escalating at higher levels of gambling spend. This tracked the habits of 6.5 million Lloyds Banking Group customers over 7 years – with key insights including:

Levels of harm were “notably stronger” once someone exceeded 3.6% monthly outgoings on gambling (£91.37 for the average household). Those who exceeded that threshold were:

33% more likely to miss a mortgage payment.

22% more likely to use an unplanned overdraft.

19% more likely to take a payday loan.

At the highest levels of harm – exceeding 10% of monthly spend – individuals were twice as likely to miss a mortgage payment compared to a non-gambler.

 

In terms of impact on communities – see these Industry_Statistics_November_2021.pdf (ctfassets.net) – p9 and 10,  and also Industry Statistics - May 2021 - Gambling Commission which shows £470m GGY for gaming machines in GB between the six months of April and Sept 2020. Of this the losses are £396.8m on B3 machines, it looks like activity on B3 grew (see the Nov 21 stats). So (admittedly very simplistic calculations) £1bn over a year in Great Britain, or c£15 per person per year. In the just short of 600k people in Sheffield that would be about £9m losses within the population. I would guess very concentrated in some groups, maybe those least able to afford it.

 

3.       A comprehensive public health  approach to gambling harm

For the first time it feels that gambling is meaningfully being consider as a public health issue. So far this has largely been in name only. It is important to emphasise the word comprehensive.

 

Many ask what IS “a public health approach to” I’m on my 4^th  iteration of a PH approach to …….Knife crime, alcohol, domestic abuse … now gambling. See previous blogs on other matters.

 

Here are four inalienable rules on “a PH approach to”, arguably generic to all “public health approaches”.

1.  a desire to focus on the tail end / high risk / vulnerable vs whole of curve – Rose hypothesis. In any concept most of the harm in the middle of the distribution. Industry would suggest we focus on the very addicted / most vulnerable. It can take 20yrs to get to reach such a level of vulnerability with lots of intervention opportunities along the way.

2. Advancing on Rose, a small % shift of a big number is still a big number. Shifting behaviour of the masses by a small amount till lead to much less harm than an enormous shift on those at highest risk.

3. Gambling is not a single entity - we have to start talking about a gambling system made up of many actors, products, and practices.

Single intervention vs whole system / whole programme. What are the leverage points (Reminder of the Foresight Obesity map. Many parallels. It’s the totality that matters

Just like the transport system for example, dangerous products should never make it into the system, those that do need to be subject to rigorous pre-market safety checks where the burden of proof of safety lies with the industry through the use of independent bodies and once in the system, products are regularly checked for safety, and the public is informed about the risk and harms by public health and other authorities who are free of vested interests.
4. Upstream interventions (a social, economic, financial, commercial environment that supports individuals) is more impactful and equitable than a focus on individual behaviour and personal responsibility

 

If I had to do the 30 second elevator pitch on the critcial essentials it would be shaped by the bullet points here 

1. There is substantial harm. Some visible, a lot not visible. A lot hard to measure. Harm across lots of domains
2. A list of target policies is necessary by not enough. Needs wrapping in a set of core principles.

1. Need something akin to Framework Convention – similar to tobacco
2. Industry influence (research, tx, policy and regulation). Is not ok. We know this from decades of experience and substantial evidence base in other areas
3. Whole pop not just pointy end.
4. Whole system not just focus on some aspects of system. Whole of govt and cross govt coord
5. Big focus on advert, sponsor and creeping normalisation

3. framing as addiction is problematic (focuses us on treating individuals)
4. on product, though there has been a big swing to thinking about online (which is critically important), there needs to be serious consideration given to land based as well. We know £ losses are substantial and concentrated in those least able to pay.
5. Strategies are needed to denormalise gambling at the popn level – including those that:

1. Address accessibility and availability of products
2. Address the factors that contribute to gambling becoming socially and culturally embedded in communities.

6. Easy wins in addressing the above = comprehensive curbs on marketing + hard hitting independent public education campaigns warning of the risks and harms associated with gambling and providing honest information about gambling industry products and tactics.
7. Those with lived experience of harm MUST be in the room when decisions are made. Govt must look those directly affected in the eye and explain decisions.
8. Funding from 1% stat levy. 

different constituencies ask for different approaches

Orienting around a single set of asks will be helpful for public health. Advocates all arguing for different things makes for a complex world. Some are absolutist, some are harm reductionist. Some very oriented on measurement, some oriented on treatment, some oriented on regulation of product, price, promotion, some oriented on all of the above but within a comprehensive framework.

 

Specific approaches to gambling harm reduction

Three broad approaches – 1) Regulation (product, advertising and sponsorship, availability), 2) treatment, 3) Education.

There are many parallels to policy and harm reduction in other spaces – alcohol, tobacco, food

Regulation (product and environment) is where most of the gain can be found in terms of reducing gambling harm.

Many have suggested specific targets for regulation – Gambling Health Alliance for eg

There is broad public support for regulation of gambling as a means to reduce harm along the lines of product, price, advertising, sponsorship, access. Exactly the same playbook as tobacco (and expect all the same countervailing tactics from industry)

There are some who will see regulation as state over reach. The gambling industry obviously frame it a different way (taken from the tobacco and alcohol playbook).

Public Health as 5^th arm of licencing act is almost an absolute necessity, esp with land based gambling and the harm this causes (see this sobering article on losses from slot machines in Victoria).

 

However, and here is a critical point, a list of policies isn’t enough – we need a comprehensive public health approach

A long list of asks for specific policy innovations is necessary, but not sufficient. It can create a perception that if we do all of the things asked then we don’t need to regulate advertising or product. It seems likely industry will find their way round specific policy measures. Fixed odds betting terminal minimum stake for example (never mind at £2 min stake can quickly consume large sums for someone on a very low income)

Ultimately I suspect we need the broader FCTC approach – allows the flexibility for legislation to rapidly respond to new industry tactics. The tactics will continually evolve, methods and products will continually evolve, and a fixed set of policy interventions might not stand the test of time. On the comparison with tobacco. Important to not forget that tobacco innovated to new tobacco products (eg heat not burn) - that’s why we need the broad legislation

This recent editorial was excellent setting out some key principles on a comprehensive approach 1) Any law should consider all gambling related harms on the population, 2) Everyone is free to spend their money as they choose. But when individual decisions have costs for society as a whole, with hard pressed health and social services picking up the pieces from activities that others have profited from, then all sectors of society have a right to be heard – lived experience must be in the room, 3) those responsible for creating harms to health should not be involved in decisions about how to prevent these harms, given the obvious conflict of interest, 4) adopt the precautionary principle. When there is reason to believe something is damaging to health, the burden of proving lack of harm lies with those who profit from it

 

A treatment system

Better treatment system is necessary but nowhere near sufficient.

(taking a lesson from tobacco - smoking cessation is hugely important but doesn’t impact significantly on population prevalence). We cant treat our way out of a PH problem (tobacco, alcohol as example in point).

A treatment system should be funded by a 1% statutory levy, owned by  the NHS, delivered to nationally agreed quality standards and an outcome framework

 

Education / awareness

While information and education are necessary, alone they do not constitute an effective and comprehensive public health response. They are an important pillar and currently the public is provided with information and warnings from the industry or those who depend on its funding, which is highly problematic.

Thus “education” may be helpful, but personalises what can be characterised as a structural and societal problem.

I would focus my education around entry 1) points into harm, 2) tactics of industry, 3) nature of products, 4) available support, 5) Raising awareness about the impact of gambling on individuals, society from a range of different entry and exit points

It is notable that the information space that is meant to 'inform' the public is awash with information that comes from sources with significant financial conflicts of interest.

Particularly in relation to children and young people - having knowledge & awareness about gambling harms should not be conflated as being commensurate with being safe from harm, esp in the long run and in environments where gambling is normalised and glamorised.

 

Where is the focal point. Perhaps problematic.

This cuts across many govt depts welcome both DCMS, HMT.

May go beyond – HO (enforcement), children (push through safeguarding), poverty and financial cliff edge (where does that rest govt responsibility wise)

Gambling enforcement is a bit scattered amongst agencies in reality ie Money Laundering – cops, Licensing SCC local enf, Gambling commission national.

 

6            The gambling industry

Most observe a large degree of industry pervasiveness into the field (policy, research, interventions). This isn’t something we would tolerate in other spaces for example BAT involvement in tobacco control. The gambling exceptionalism needs to be addressed - there is no other industry I am aware of that is allowed to 'mark its own homework' to the extent that the gambling industry does

Many have documented range of industry tactics and practices used by the electronic gambling machine industry to normalise their products in community settings, maximise profit and prevent regulatory reform. These include promoting EGM venues as ‘family-friendly’ spaces, which may soften the perception of risks associated with the venue; innovation with the design of EGMs to ensure individuals spend more time and money on machines; and using donations to political parties to influence public policy. Political donations might be modest but combined with smart use of different arguments to appeal to all sides of political thinking they can be impactful in shaping policy makers opinions. This has been well documented in other industries also.

There is an obvious commercial interest in policy here with significant power behind it. The tactics of industry are similar to tactics of other industries such as tobacco, food and alcohol. Specific on gambling see the Paul Merson documentary, and van Schalkwyk.  

The most commonly used industry line is that 1) “we will self regulate”. This is a line that has been used by tobacco, alcohol, fast food and (in other countries firearms) for about 30 years and 2) we should focus on treatment for those deeply addicted and educate the wider population.

Industry will argue that people need to make better choices, that education is a big part of the answer, that we should have better treatment for those addicted. This is a mirror image of the arguments of the tobacco industry in the 70s through to the early 90s. People make choices in an environment that is very enabling, especial worries about online gambling which is weakly regulated.

Industry will likely frame problems in specific ways to shift attention away from the most impactful interventions in terms of reducing harm.

When industries selling highly profitable, yet harmful, products (eg, tobacco, alcohol, opioids, and oil) are faced with clear evidence of the resulting harms, the threat of government regulation, and declining public legitimacy, one of their first moves has repeatedly been to cast doubt on the science, distorting the evidence base to influence the public discourse, delay regulation, and restore their legitimacy. See this excellent thread and paper on industry tactics to sow doubt and spread misinformation to downplay harms, and here specifically on the “When the fun stops stop” campaign.

There is already enough to argue that many of the established methods to counter other harmful but legal products (eg, tobacco and alcohol)—restricting access, availability, and advertising, and denormalisation and evidence-based counter-marketing—can be used to guide interventions to prevent gambling harms.

 

 

 

7            Talking points

personal responsibility

who is obliged to do what – see this story on gambling firms asking punters for their payslips

“moral obligation” only applies to those experiencing gambling addiction not companies whose business model is built on causing harm…

The discussions this week about pay slips and single view and tougher regulator, they all 'sound' great but I fear are a bit reminiscent of what was being said around the time of the 2005 Act and the role of the regulator.

Spot on about the "moral obligation" rhetoric, just as with the whole personal responsibility argument, the onus on business to act responsibly, ethically and to prove safety is hardly ever engaged with.

 

“industry will self regulate”

How many times have we heard this. Right the way back to (and well before) the Approved Code of Conduct around smoking in public places

“When the Fun Stops, Stop”: An analysis of the provenance, framing and evidence of a ‘responsible gambling’ campaign. Key themes - analysis of gambling industry self sponsored public health campaign, millions vs minority, wrongly framed mechanisms and solutions, over states the effectiveness of self regulation, misses out critical issues

 

“Gambling is not tobacco”

Potentially harmful product

We don’t want kids to think that a potentially harmful product is one we should engage with

Bring normalisation into the harm language quickly

 

“We will make sure we protect “high risk” or “problematic” gamblers”

People don’t just become “problem gamblers”, there is often a long journey with many opportunities to intervene.

Industry would suggest we focus on the very addicted / most vulnerable. It can take 20yrs to get to reach such a level of vulnerability with lots of intervention opportunities along the way.

 

“A harmless leisure pursuit”

How to think about it - Extent to which we frame gambling as a leisure pursuit vs something that is inherently harmful

“it is a leisure activity” …..

But features in upcoming addiction strategy

We don’t talk about Tx pathways for the opera, or the Royal History Museum

So there is acknowledgement of harm

 

Extent to which “We need gambling industry on side”

We don’t think in this way wrt to tobacco, or alcohol, or petrochemicals

 

“We need more data”

DON’T need more prevalence studies ….. play into industry hands as can downplay the harm

There are some within petrochemical industry that say the same about climate change

 

“you simply want to stop all gambling” / “You are anti gambler”

Harm reduction is all. “We are not seeking an endgame for gambling (as we are tobacco) but seeking a low harm scenario”

No. As per decades old discussion on anti smoker (it is a well trod industry line). Most are anti harm FROM gambling, and the question becomes about more or less effective strategies to reduce harm.

 

advertising and sponsorship

“you need to demonstrate a direct link between advertising and sponsorship and measurable harm” – affects appetite of govt for intervention

“We cant do anything till we have “causal evidence” that ads themselves cause harm”……. No gambling is a system …..all part of a wider fabric

We have CLEAR evidence on exposure to tobacco and alcohol gambling

Lottery is one of the most normalising forms of gambling. Most of the advertising is at knee hight

Its in the fun dept of govt, this portrays an attractive thing for kids

Gam Comm report on advertising

Linked to things we love – sport, leisure

DON’T allow slippage to narrative framed on “harmful” marketing

360 marketting is exactly what it is

When you look after young people you are also exposing adults

Exposure vs targeting - Children are caught in the crossfire. Always talk exposure, always talk children

Today’s 14yr old is a customer for industry at 18, and normalising attitudes is a very legitimate target for someone who wants to create a future customer. Often a perception that gambling is a risk free activity. We know that product and brand recognisition in young people is good.

Listening to the voices of young people critical. Adults don't become vulnerable or heavily addicted by accident .... often the path might start in younger years (often not by actual participation but  normalising). The voices of and protection of young people is critical to this debate

In the round there are 5 broad sets of recommendations from young epole themselves – reduce availability and accessibility, change infrastructure to limit choices, counter frame commercial messages about gambling

Sponsorship is seen as a good thing – it can give the perception the company is doing something positive for their team

There is a legitimate discussion to be had on PR vs PH. There are some who go as far as to say that industry funding of treatment is a public relations exercise

What are views of young people themselves – mostly they are savvy and they get it.

A lack of strong actions make govt might be perceived to make govt as responsible for harm as industry.

 

 

A strategy must be founded on a core principle of personal responsibility

Much of our exposure to the risk (both product and environment) is not in our personal control.

Regulation is by far more important as it sets the context into which people make “responsible choices”. Personal responsibility needs to go hand in hand with government responsibility and industry responsibility. 

This is not a “normal” consumer product like a washing machine. It is an addictive product and an unsafe environment.

 

It requires a collective effort, and we know that one of the key levers to encourage people to manage their risk, is to appeal to the importance of that collective effort and the impact of our individual behaviours on others.

The obvious counter challenge - If we ARENT people to take personal responsibly what ARE we asking. We ARE asking for personal responsibility …. It is necessary, but not sufficient. A strategy that focus solely on managing personal risk will always be sub-optimal. Its more complex than simple binary. We make choices moulded by our social and economic context and the environment we live in. Individual vs social risk

 

8            Window of opportunity

There is a window of opportunity to reduce gambling harm both locally and nationally and to get ahead of the curve.

The UK has one of the most liberal gambling markets in the world, supervised by a regulatory system that oversight bodies fear does not to have the capacity or the data to regulate the industry in the public interest.  This policy system has promoted self-regulation and industry-regulator partnerships as standard.

The nature of the market has shifted substantially in the last decade or so – more products, more addictive  products, more marketing across more forms of media, sponsorship, shift to online. Accordingly the level of concern from clinicians and documented harm has also shifted with the nature of the market. Accordingly the level of concern from clinicians and documented harm has also shifted

 

With the UK Government's review of the Gambling Act 2005, and local review of  policy there is a window of opportunity to change the gambling policy system.. We don’t know how gambling products will change over coming years, but they have changed massively over the last decade and more harm has come from this. It is a reasonably safe assumption that trend will continue.

 

Acknowledgements

Huge thanks to May Van Schalkwyk (LSHTM) and Samantha Thomas (Deakin) for their thoughts and ideas in shaping this one. Also huge thanks to my old boss Dr Ian Cameron from whom I got an introduction into this area.

 

References:

Ipsos MORI (2015) The Prevalence of Underage Gambling. A research study among 11-15 year olds: Young People Omnibus 2015. Birmingham: Gambling Commission

Kenyon, A., Ormerod, N., Parsons, D. & Wardle, H. (July 2016). Problem gambling in Leeds: Research Report for Leeds City Council. Leeds Beckett University.

PHE Public Health Profiles: People estimated to have gambled in past year: % adults, People estimated to have gambled (excluding Lottery) in past year: % adults (Data source: NatCen Gambling Behaviour in England and Scotland: Findings from the Health Survey for England 2012 and Scottish Health Survey 2012)

Wardle, H. (2015) Exploring area-based vulnerability to gambling-related harm: Who is vulnerable? Findings from a quick scoping review. London: Westminster City Council.

Wardle H, et al. (2007) British Gambling Prevalence Survey 2007. London: National Centre for Social Research

van Schalkwyk et al. A public health approach to gambling regulation: countering powerful influences Lancet Public Health, June 2021 https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00098-0/fulltext?rss=yes

PHE evidence summary - Gambling-related harms evidence review: summary. https://www.gov.uk/government/publications/gambling-related-harms-evidence-review