Aid and a bet: A brief look at the prevention of problem gambling

While prevention efforts targeting addictive disorders are widely used, there are relatively limited data are available on their effectiveness (particularly in the gambling studies field). According to the US Preventive Services Task Force, prevention has historically been divided into three stages. The term primary prevention has been used to describe measures employed to “prevent the onset of a targeted condition”. Secondary prevention has been used to describe measures that “identify and treat asymptomatic persons who have already developed risk factors or pre-clinical disease but in whom the condition is not clinically apparent”. Tertiary prevention has been used to describe “efforts targeting individuals with identified disease in which the goals involve restoration of function, including minimizing or preventing disease-related adverse consequences”. These divisions of prevention thus focus on different targets, with primary efforts tending to target the general population, secondary efforts at risk or vulnerable groups, and tertiary efforts individuals with an identified disorder.

Primary prevention is typically considered the most cost-effective form of prevention as it helps reduce suffering, cost and burden associated with a disorder. Primary prevention efforts related to problem gambling have generally involved education initiatives. Examples include television commercials, billboards, posters, and postcards, that may feature brief problem gambling screening instruments or advertise gambling helplines and treatment services. Despite widespread use, most primary prevention efforts in gambling have not been empirically validated.

The content and impact of primary prevention is strongly influenced by knowledge of the impact of the behaviour or disorder being prevented. For example, prevention efforts targeting tobacco smoking cessation have changed significantly as more information concerning the health impact of tobacco smoke have become available. Unfortunately, few large-scale, well-designed studies have investigated the health impact of different levels or types of gambling (e.g., recreational, problem, and pathological).

Some primary prevention efforts targeting children and adolescents may influence adult gambling behaviors. Some of these studies have published promising results but all studies have shortcomings (e.g., cross-sectional designs that don’t allow for assessment of lasting positive effects on gambling attitudes or behaviour). Basically, it’s unclear if the positive effects found will be maintained into adulthood or if the same interventions employed on adolescent populations would be effective for adults. Research on prevention programs outside of the gambling field has suggested that regardless of delivery mode (didactic lecture, videotapes, posters, pamphlets, guest speakers etc.), the ‘information only’ approach has relatively little effect on behavioural change.

Another feature to be considered in primary prevention is the impact of gambling availability on the development of problem gambling. Over the past several decades, there has been a rapid increase in the availability of legalized gambling worldwide. Data suggest that concurrent with the increase in availability there have been increase in the rates of recreational, problem and pathological gambling. The extent to which gambling should be regulated and/or restricted remains an area of active debate, with the decisions holding considerable potential impact on public health and prevention efforts. In summary, although primary prevention efforts related to adult gambling exist, they are relatively few in number, particularly when considering the public health impact of problem gambling.

Secondary prevention efforts involve measures that target individuals with risk factors for or pre-clinical forms of a disorder. Secondary prevention measures in general constitute important interventions in general medical settings. Although it is likely that generalist physicians encounter individuals with gambling problems in their provision of clinical care, the extent to which they are trained to examine for or feel comfortable in assessing gambling problems warrants consideration. However, a significant minority of gamblers report health problems as a direct result of their gambling. This indicates that gambling in its most excessive forms should be viewed as a serious health issue to be taken seriously by the medical profession. Adverse health consequences for both the gambler and their partner include depression, insomnia, intestinal disorders, migraines, and other stress-related disorders. General practitioners routinely ask patients about smoking and drinking but gambling is something that is not generally discussed. Problem gambling may be perceived as a somewhat ‘grey area’ in the field of medicine and it is therefore is very easy to deny that medics should be playing a role. If the main aim of practitioners is to ensure the health of their clients, then it is quite clear that an awareness of gambling and the issues surrounding should be an important part of basic knowledge.

Efficient screening methods for problematic gambling behaviours could be of significant value in general medical settings. Several brief screening instruments for problem and pathological have been developed. Although it is likely too early to develop practice guideline for problem and pathological gambling prevention efforts within a general medical setting, generalist physicians could regularly assess patients’ gambling histories, sensitively broach the topic of the possible existence of gambling problems with those patients suspected of engaging problematically in gambling, thoughtfully motivate individuals with gambling problems to seek treatment, and appropriately refer individuals with gambling problems to a self-help group or a gambling to facilitate engagement in locally available gambling treatment.

Brief screening instruments could also be of significant utility in other settings, including mental health and addiction treatment offices, jails and other forensic facilities, and gambling venues. Individuals within these settings should be aware of the high rates of problem gambling in specific groups (e.g., males, adolescents, and individuals with histories of incarceration or psychiatric [including substance use] disorders). Given the high rates of co-occurrence of gambling and other psychiatric disorders, screening of individuals with problem or pathological gambling for other psychiatric disorders (and vice versa) could enhance tertiary prevention efforts (i.e., providing treatment that more effectively reduces the harm associated with each disorder).

Individuals attending gambling venues represent important areas for secondary prevention efforts. Many gambling venues train their staff to identify potential problem or pathological gamblers and advertise within the facilities methods for patrons to obtain help (e.g., through gambling helplines and/or self-exclusion programs). Specific populations, although at arguably lower risk, might require unique prevention efforts. For example, gambling problems are more prevalent in men than women, and there exist gender-related differences in problem gambling behaviours (e.g., women generally beginning to gamble and developing problems with gambling later in life). As such, prevention efforts for men and women might preferentially target specific venues or age groups.

Tertiary prevention efforts, involving reducing disorder-related harm in affected individuals, include treatment efforts, and behavioural and pharmacological therapies for problem gambling. ‘Early’ tertiary prevention efforts involve moving individuals with recently recognized gambling problems into treatment (e.g., through gambling helplines) and non-treatment-related methods for helping individuals with gambling problems refrain from gambling (e.g., through availability and maintenance of casino self-exclusion policies).

Gambling helplines are widely around the world. Information from helpline callers can help enhance prevention efforts. However, further work is needed to examine directly the effectiveness of helplines with regard to treatment referral follow-up. That is, information obtained from callers willing to be called back several months following initial contact with the helpline would be valuable in assessing the extent to which problem gamblers have benefited from the helpline intervention. Self-exclusion policies exist in casinos and other gambling venues (e.g., bookmakers) around the world. Although the precise rules and regulations vary according to geographic location and individual casino, they generally involve voluntary self-exclusion for a period of time (e.g., 6 months to five years).

Increased knowledge regarding the impact of different types/levels of gambling behaviours on health and wellbeing would be extremely valuable in generating guidelines for healthy gambling and primary prevention efforts. An increased understanding of high-risk and vulnerable populations, facilitated through biological, psychological/psychiatric and social investigations, and the natural histories of gambling behaviors within these groups will help enhance secondary and early tertiary prevention efforts. As in other fields of medicine, the effectiveness of individual prevention strategies will need to be empirically validated. Targeted efforts in these areas should lead to a decrease in suffering attributable to problem gambling.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading 

Griffiths, M.D. (2003). Adolescent gambling: Risk factors and implications for prevention, intervention, and treatment. In D. Romer (Ed.), Reducing Adolescent Risk: Toward An Integrated Approach (pp. 223-238). London: Sage.

Griffiths, M.D. (2007). Gambling Addiction and its Treatment Within the NHS. London: British Medical Association.

Griffiths, M.D. (2008). Youth gambling education and prevention: Does it work? Education and Health, 26, 23-26.

Griffiths, M.D. (2010). The gaming industry’s role in the prevention and treatment of problem gambling. Casino and Gaming International, 6(1), 87-90.

Griffiths, M.D. (2012). Self-exclusion services for online gamblers: Are they about responsible gambling or problem gambling? World Online Gambling Law Report, 11(6), 9-10.

Hayer^, T., Griffiths, M.D. & Meyer, G. (2005). The prevention and treatment of problem gambling in adolescence. In T.P. Gullotta & G. Adams (Eds). Handbook of Adolescent Behavioral Problems: Evidence-Based Approaches to Prevention and Treatment (pp. 467-486). New York: Springer.

Hayer, T. & Griffiths, M.D. (in press). The prevention and treatment of problem gambling in adolescence. In T.P. Gullotta & G. Adams (Eds). Handbook of Adolescent Behavioral Problems: Evidence-based Approaches to Prevention and Treatment (Second Edition). New York: Kluwer.

Korn, D., Shaffer HJ. (1999). Gambling and the health of the public: Adopting a public health perspective. Journal of Gambling Studies, 15, 289-365.

Meyer, G., Hayer, T. & Griffiths, M.D. (2009). Problem Gaming in Europe: Challenges, Prevention, and Interventions. New York: Springer.

Potenza, M. & Griffiths, M.D. (2004). Prevention efforts and the role of the clinician. In J.E. Grant & M. N. Potenza (Eds.), Pathological Gambling: A Clinical Guide To Treatment (pp. 145-157). Washington DC: American Psychiatric Publishing Inc.

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

Shaffer, H., Korn DA. (2002). Gambling and related mental disorders: A public health analysis. Annual Review of Public Health, 23, 171-212.

US Preventive Services Task Force (1996). Guide to clinical preventative services (2nd edition). Baltimore, MD: Williams & Wilkens.