Monthly Archives: May 2017
Doctor, doctor: What can British GPs do about problem gambling?
A study published in the British Journal of General Practice in March 2017 reported that of 1,058 individuals surveyed in GP waiting rooms in Bristol (UK), 0.9% were problem gamblers and that a further 4.3% reported gambling problems that “were low to medium severity”. This is in line with other British studies carried out over the last decade which have reported problem gambling prevalence rates of between 0.5% and 0.9%.
I have long argued that problem gambling is a health issue and that GPs should routinely screen for gambling problems. Back in 2004, I published an article in the British Medical Journal about why problem gambling is a health issue. I argued that the social and health costs of problem gambling were (and still are) large at both individual and societal levels.
Personal costs can include irritability, extreme moodiness, problems with personal relationships (including divorce), absenteeism from work, neglect of family, and bankruptcy. Adverse health consequences for problem gamblers and their partners include depression, insomnia, intestinal disorders, migraine, and other stress related disorders. In my BMJ article I also noted that analysis of calls to the GamCare national gambling helpline indicated that a small minority of callers reported health-related consequences as a result of their problematic gambling. These included depression, anxiety, stomach problems, and suicidal ideation. Obviously many of these medical problems arise through the stress of financial problems but that doesn’t make it any less of a health issue for those suffering from severe gambling problems.
Research published in the American Journal of Addictions has also shown that health-related problems can occur as a result of withdrawal effects. For instance, one study by Dr. Richard Rosenthal and Dr. Henry Lesieur found that at least 65% of pathological gamblers reported at least one physical side effect during withdrawal, including insomnia, headaches, loss of appetite, physical weakness, heart racing, muscle aches, breathing difficulty, and chills.
Based on these findings, problem gambling is very much a health issue that needs to be taken seriously by all in the medical profession. GPs routinely ask patients about smoking cigarettes and drinking, but gambling is something that is not generally discussed. Problem gambling may be perceived as a grey area in the field of health, and it is therefore very easy for those in the medical profession not to have the issue on their wellbeing radar. If the main aim of GPs is to ensure the health of their patients, then an awareness of gambling and the issues surrounding it should be an important part of basic knowledge and should be taught in the curriculum while prospective doctors are at medical school. One of the reasons that GPs don’t routinely screen for problem gambling is because they are not taught about it during their medical training and therefore do not even think about screening for it in the first place. As I recommended in a report commissioned by the British Medical Association, the need for education and training in the diagnosis, appropriate referral and effective treatment of gambling problems must be addressed within GP training. More specifically, GPs should be aware of the types of gambling and problem gambling, demographic and cultural differences, and the problems and common co-morbidities associated with problem gambling. GPs should also understand the importance of screening patients perceived to be at increased risk of gambling addiction, and should be aware of the referral and support services available locally.
I also recommended that treatment for problem gambling should be provided under the NHS (either as standalone services or alongside drug and alcohol addiction services) and funded by gambling-derived profit revenue.
Back in 2011, Dr. Jane Rigbye and myself published a study using Freedom of Information requests to ask NHS trusts if they had ever treated pathological gamblers. Only 3% of the trusts had ever treated a problem gambler and only one trust said they offered dedicated help and support. I’m sure if we repeated the study today, little will have changed.
It is evident that problem gambling is not, as yet, on the public health agenda in the UK. NHS services – including GP surgeries – need to be encouraged to see gambling problems as a primary reason for referral and a valid treatment option. Information about gambling addiction services, in particular services in the local area, should be readily available to gamblers and GP surgeries are a good outlet to advertise such services. Although some gambling services (such as GamCare, the gambling charity I co-founded) provide information to problem gamblers about local services, such information is provided to problem gamblers who have already been proactive in seeking gambling help and/or information. Given that very few GPs could probably treat a problem gambler, what they must have is the knowledge of who they can refer their patients to.
Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Calado, F. & Griffiths, M.D. (2016). Problem gambling worldwide: An update of empirical research (2000-2015). Journal of Behavioral Addictions, 5, 592–613.
Cowlishaw, S., Gale, L., Gregory, A., McCambridge, J., & Kessler, D. (2017). Gambling problems among patients in primary care: a cross-sectional study of general practices. British Journal of General Practice, doi: bjgp17X689905
Griffiths, M.D. (2001). Gambling – An emerging area of concern for health psychologists. Journal of Health Psychology, 6, 477-479.
Griffiths, M.D. (2004). Betting your life on it: Problem gambling has clear health related consequences. British Medical Journal, 329, 1055-1056.
Griffiths, M.D. (2007). Gambling Addiction and its Treatment Within the NHS. London: British Medical Association (ISBN 1-905545-11-8).
Griffiths, M.D. & Smeaton, M. (2002). Withdrawal in pathological gamblers: A small qualitative study. Social Psychology Review, 4, 4-13.
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.
Rosenthal, R., & Lesieur, H. (1992). Self-reported withdrawal symptoms and pathological gambling. American Journal of the Addictions, 1, 150–154.
Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011). British Gambling Prevalence Survey 2010. London: The Stationery Office.
Wardle, H., Sproston, K., Orford, J., Erens, B., Griffiths, M.D., Constantine, R. & Pigott, S. (2007). The British Gambling Prevalence Survey. London: The Stationery Office.
Dispensing wisdom: ATMs on the gaming floor
The gambling industry has long been trying to perfect techniques that keep players on their premises and gambling on their games longer. In short, their aim is to introduce facilities that maximize their bottom line profits. In super-casinos around the world, restaurants are often positioned in the centre so that customers have to pass the gaming areas before and after they have eaten. Live entertainment areas for music or sporting events (e.g., boxing matches) are also positioned similarly.
This strategy is often combined with the deliberate use of circuitous paths to keep customers in the casino longer, the psychology being that if the patrons are in the casino longer they will spend more money. Large US casinos have got this down to a fine art. A number of years ago I remember going to a live music concert at the MGM Grand in Las Vegas and on entering the casino it took me a 20- to 25-minute walk past thousands of slot machines and gaming tables before I even arrived at the auditorium! Although I didn’t gamble during the 45 minutes I was exposed to the slot machines to and from the casino entrance, I did wonder how many of the thousands in the audience had succumbed at some point.
UK gambling venues are now increasingly offering other non-gambling services (such as snack facilities and live entertainment) in a bid to either attract new customers or to keep those already in the venue as long as possible. The 2005 Gambling Act allowed even more of this diversification. It is also worth noting that some forms of gambling (such as slot machines) are far more profitable than other forms (such as table games). What’s more, slot machines don’t need a croupier to deal or spin the roulette ball. This means that most casinos worldwide are now dominated by slot machines in preference to other forms of gambling (although there are places like Macao where table games are preferred over slot machines).
Two of the biggest changes that have occurred in casinos worldwide over the last 20 years that appear to aid such a ‘maximisation’ strategy are the introduction of cash machines onto the gaming floors and the introduction of note acceptors to electronic gaming machines. At a very simplistic level, facilities like these create and enhance convenience gambling.
Note acceptors are very popular in countries like US, Canada and Australia. The gaming industry argues that note acceptors are popular with customers and enhance the playing experience in that they make life a little bit easier for the punter when standing in front of a slot machine not to have to keep going to the cashier for change. However, there is a very fine line between customer enhancement and customer exploitation. Note acceptors have the capacity to increase spending in a number of direct and indirect ways. Firstly, note acceptors increase privacy for the punter. More specifically for the punter, it avoids the potential embarrassment of letting gaming staff, friends, family or even other customers know how much they are spending. Secondly, note acceptors can aid in suspending judgment whereby more cash is transferred to credit in one go. Thirdly, note acceptors minimise breaks as players do not need to leave the machine to get change. Not taking breaks minimises ‘time out’ periods where punters can think more rationally about the money they have spent. A study carried out in Canadian casinos showed that the amount initially put into a slot machine by punters was twice as high on machines that had note acceptors. Although this is only one study, it does seem to suggest that gamblers spend more when a note acceptor is present.
Like note acceptors, the introduction of automated cash dispensers onto the casino floor also increases privacy for the punter. Although studies have found that only a relatively small proportion of casino patrons seldom use cash dispensers at gambling venues, a significantly high proportion of problem gamblers do so. One study in New Zealand carried out by Professor Max Abbott found that only 2% of all adults interviewed in a national survey considered that greater access to these facilities led to an increase in their gambling. Among problem gamblers, this figure was over eight times as high at 17%.
In Australia, a study led by Professor Jan McMillen also found much greater cash dispenser usage at gambling venues by problem gamblers when compared to non-problem gamblers. They also found that problem gamblers withdrew larger amounts. Money accessed in this way was most often for the purchase of both alcohol and gambling. They concluded that convenient access to cash dispenders in gambling venues contributed to greater expenditure and was a contributory factor in the development and persistence of gambling problems.
A number of other studies have reported similar findings. Problem gamblers frequently mention that adjacent access to cash dispensers is one of the most frequently mentioned reasons for gambler’s exceeding their planned spending limit. Research has also shown that both problem and non-problem gamblers would prefer cash dispensers to be located away from gambling venues. It would seem that the only people who want cash dispensers on gambling premises are the operators themselves, mainly because they know it increases revenue.
Dr Mark Griffiths, Professor of Behavioural Addictions, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
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Griffiths, M.D. (2009). Casino design: Understanding gaming floor influences on player behaviour. Casino and Gaming International, 5(1), 21-26.
Griffiths, M.D. & Parke, J. (2003). The environmental psychology of gambling. In G. Reith (Ed.), Gambling: Who wins? Who Loses? pp. 277-292. New York: Prometheus Books.
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McCormack, A. & Griffiths, M.D. (2013). A scoping study of the structural and situational characteristics of internet gambling. International Journal of Cyber Behavior, Psychology and Learning, 3(1), 29-49.
McMillen, J., Marshall, D., and Murphy, L. (2004). The Use of ATMs in ACT Gaming Venues: An Empirical Study. ANU Centre for Gambling Research, Canberra.
Parke, J. & Griffiths, M.D. (2007). The role of structural characteristics in gambling. In G. Smith, D. Hodgins & R. Williams (Eds.), Research and Measurement Issues in Gambling Studies (pp.211-243). New York: Elsevier.
Wood, R.T.A., Shorter, G.W. & Griffiths, M.D. (2014). Rating the suitability of responsible gambling features for specific game types: A resource for optimizing responsible gambling strategy. International Journal of Mental Health and Addiction, 12, 94–112.