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The national wealth service: Problem gambling is a health issue

Over the last decade, the United Kingdom has undergone major changes of gambling legislation (most notably, the 2005 Gambling Act that came into force on September 1, 2007). The Gambling Act has provided the British public with increased opportunities and access to gambling like they have never seen before. Gambling legislation was revolutionized and many of the tight restrictions on gambling dating back to the 1968 Gaming Act were relaxed (particularly in relation to the advertising of gambling). The deregulation of gambling has also been coupled with the many new media in which people can gamble (internet gambling, mobile phone gambling, interactive television gambling, gambling via social networking sites). Given the expected explosion in gambling opportunities, is this something that the health and medical professions should be concerned about?

Gambling has not been traditionally viewed as a public health matter although research into the health, social and economic impacts of gambling has grown considerably since the 1990s. In August 1995, the British Medical Journal published an editorial called ‘Gambling with the nation’s health?’ which argued that gambling was a health issue because it widened the inequalities of income and that there was an association between inequality of income in industrialized countries and lower life expectancy. However, there are many other more specific reasons why gambling should be viewed as an issue for the medical profession.

According to the last British Gambling Prevalence Survey (BGPS) published in 2011, just under 1% of the British population have a severe gambling problem although the rate is approximately twice as high in adolescents, particularly as a result of problematic slot machine gambling. Disordered gambling is characterized by unrealistic optimism on the gambler’s part. All bets are made in an effort to recoup their losses. The result is that instead of “cutting their losses”, gamblers get deeper into debt pre-occupying themselves with gambling, determined that a big win will repay their loans and solve all their problems.

It is clear that the social and health costs of problem gambling can be large on both an individual and societal level. Personal costs can include irritability, extreme moodiness, problems with personal relationships (including divorce), absenteeism from work, family neglect, and bankruptcy. I have also reported in a number of my papers (including a 2007 report I wrote for the British Medical Association) that there can also be adverse health consequences for both the gambler and their partner including depression, insomnia, intestinal disorders, migraines, and other stress-related disorders. In the UK, preliminary analysis of the calls to the national gambling helpline also indicated that a significant minority of the callers reported health-related consequences as a result of their problem gambling. These include depression, anxiety, stomach problems, other stress-related disorders and suicidal ideation.

There are also other issues relating to problem gambling that may have medical consequences. One US study published in the Journal of Emergency Medicine by Dr. Robert Muellman and his colleagues found that intimate partner violence (IPV) was predicted by pathological gambling in the perpetrator. In a sample of 286 women admitted to the emergency department at a University Hospital in Nebraska, findings revealed that a woman whose partner was a problem gambler was 10.5 times more likely to be a victim of IPV than partners of a non-problem gambler.

Health-related problems due to problem gambling can also result from withdrawal effects. In a study published in the American Journal of the Addictions, 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, upset stomach, loss of appetite, physical weakness, heart racing, muscle aches, breathing difficulty and/or chills. Their results were also compared to the withdrawal effects from a substance-dependent control group. They concluded that pathological gamblers experienced more physical withdrawal effects when attempting to stop than the substance-dependent group. I also found similar things in a small study that I published in the Social Psychological Review (with Michael Smeaton).

Pathological gambling is very much the ‘hidden’ addiction. Unlike (say) alcoholism, there is no slurred speech and no stumbling into work. Furthermore, overt signs of problems often don’t occur until late in the pathological gambler’s career. If problem gambling is an addiction that can destroy families and have medical consequences, it becomes clear that medical professionals should be aware of the effects of gambling in just the same way that they are with other potentially addictive activities like drinking (alcohol) and smoking (nicotine).

However, gambling addiction is an activity that is not (at present) being treated via the British National Health Service (NHS). This was shown in a paper that I published with Dr. Jane Rigbye in a paper we published in a 2011 issue of the International Journal of Mental Health and Addiction. We sent a total of 327 letters were sent to all Primary Care Trusts, Foundation Trusts and Mental Health Trusts in the UK requesting information about problem gambling service provision and past year treatment of gambling problems within their Trust under the Freedom of Information Act. Our findings showed that 97% of the NHS Trusts did not provide any service (specialist or otherwise) for treating those with gambling problems (i.e., only nine Trusts provided evidence of how they deal with problem gambling). Only one Trust offered dedicated specialist help for problem gambling. Our study showed there was some evidence that problem gamblers may get treatment via the NHS if that person has other co-morbid disorders as the primary referral problem.

Problem gambling is very much a health issue that needs to be taken seriously by all within the health and medical professions. 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 health and it is therefore very easy to deny that those in the medical profession should be playing a role. If the main aim of practitioners is to ensure the health of their patients, then it is quite clear that an awareness of gambling and the issues surrounding it should be an important part of basic knowledge.

As briefly outlined above, opportunities to gamble and access to gambling have increased because of deregulation and technology. What has been demonstrated from research evidence in other countries is that – in general – where accessibility of gambling is increased there is an increase not only in the number of regular gamblers but also an increase in the number of problem gamblers – although this may not be proportional. This obviously means that not everyone is susceptible to developing gambling addictions but it does mean that at a societal (rather than individual) level, in general, the more gambling opportunities, the more problems. Other countries such as Australia, Canada and New Zealand have seen increases in problem gambling as a result of gambling liberalization. In the UK, the last BGPS showed that problem gambling in Great Britain had increased by 50% compared to the previous BGPS published in 2007. (However, the latest data from the combined Health Survey for England and the Scottish Health Survey in 2014 reported that problem gambling had fallen to about 0.5%).

Gambling is without doubt a health and issue and there is an urgent need to enhance awareness within the medical and health professions about gambling-related problems and to develop effective strategies to prevent and treat problem gambling. The rapid expansion of gambling represents a significant public health concern and health/medical practitioners also need to research into the impact of gambling on vulnerable, at-risk, and special populations. It is inevitable that a small minority of people will become casualties of gambling in the UK, and therefore help should be provided for the problem gamblers. Since gambling is here to stay and is effectively state-sponsored, the Government should consider giving priority funding (out of taxes raised from gambling revenue) to organizations and practitioners who provide advice, counselling and treatment for people with severe gambling problems.

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

Further reading

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.

Griffiths, M.D. (2011). Adolescent gambling. In B. Bradford Brown & Mitch Prinstein (Eds.), Encyclopedia of Adolescence (Volume 3) (pp.11-20). San Diego: Academic Press.

Griffiths, M.D., Scarfe, A. & Bellringer, P. (1999). The UK National telephone Helpline – Results on the first year of operation. Journal of Gambling Studies, 15, 83-90.

McKee, M. & Sassi, F. (1995). Gambling with the nation’s health. British Medical Journal, 311, 521-522.

Muelleman, R. L., DenOtter, T., Wadman, M. C., Tran, T. P., & Anderson, J. (2002). Problem gambling in the partner of the emergency department patient as a risk factor for intimate partner violence. Journal of Emergency Medicine, 23, 307-312.

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.

Setness, P.A. (1997). Pathological gambling: When do social issues become medical issues? Postgraduate Medicine, 102, 13-18.

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., Seabury, C., Ahmed, H., Payne, C., Byron, C., Corbett, J. & Sutton, R. (2014). Gambling behaviour in England and Scotland: Findings from the Health Survey for England 2012 and Scottish Health Survey 2012. London: NatCen.

Gambling in Great Britain: What are the real issues the Government need to think about?

You may remember that back in 2007, Gordon Brown’s first major decision as Prime Minister was to put on ice the building of a Las Vegas-style ‘super-casino’ in Manchester. At a stroke, Brown distanced himself from the policies of Tony Blair while appearing to take the moral high ground over proposals that had attracted fierce condemnation from both inside and outside Parliament. In truth, the decision almost completely missed the point. Whether or not Manchester has a super-casino will make no practical difference to the ongoing rise of gambling in our society. Furthermore, the Labour Government’s apparent U-turn did little to protect those who are most vulnerable to gambling addiction. If anything, it was a further example of the Government’s lack of joined-up thinking over the whole issue of gambling.

Whether we like it or not, widespread gambling is here to stay. Over the last 10 years, the introduction of fixed odds betting terminals in betting shops, internet gambling (including online poker, online bingo and online betting exchanges), spread-betting, mobile phone gambling, and interactive television gambling have revolutionized the world of gambling. Gambling has slowly moved away from dedicated gambling venues and into our home and workplaces.

A large and growing number of people now enjoy gambling and see it as a socially acceptable form of entertainment, rather than a stigma-laden vice. For many people, a night at a casino is seen as little different – and certainly no more expensive – than a trip to a Premiership football match. The world has changed and Government policy and legislation has to keep up – or risk being discredited. Online poker and betting exchanges are now the two big growth areas on the internet. Men and women are now equally likely to gamble. The genie cannot suddenly be put back in the bottle.

The political challenge now, which the Coalition Government are only beginning to fully grasp, is to safeguard those most at risk from problem gambling while educating gamblers about the risks they face. There is no doubt that gambling addiction can wreck lives, turn some previously law-abiding people to crime, and contribute to relationship breakdowns. Gambling – like drinking, sex or even driving a car – is an adult activity that contains an element of risk. A small number of people will get into problems, but the legislator’s job is not to ban it, but to ensure that there are proper safeguards, education and help for those who become problem gamblers.

The first principle should be to protect the vulnerable. And the first thing I would do is ban all child gambling. Slot machines are often described as the ‘crack cocaine’ of gambling. The bright lights, noises, rapid turnover, relatively small stake and frequent small wins or ‘near wins’ combine to make a potent mix for gambling addicts. Yet in this country there are thousands of machines that children can legally play on, mainly in family leisure centres and seaside amusement arcades.

The Government should also reconsider a statutory levy on the gaming industry to help pay for research into problem gambling, treatment, education and prevention. Over the last few years – and to their credit – the gaming industry has given up to £5 million a year as a voluntary contribution to the Responsible Gambling Fund, but with more than 500,000 adult problem gamblers in the UK, this represents a contribution of around £10 per problem gambler, which I believe is inadequate. I would suggest that we examine the examples of other countries that have liberalized gambling such as Australia, where in some jurisdictions the gambling industry has to pay a mandatory contribution of around one per cent of profits to pay for social welfare. This would provide millions of extra pounds for research, education and treatment, yet would be relatively small change to the industry.

Another nettle the Government has failed to grasp is bringing all gambling (including spread betting, lottery, and scratchcards) under the control of a single regulatory authority. Only in this way can the British Government take an overall strategic view –  for example making sure that all pro-gambling advertising is balanced by educational advertising.

The great irony of the previous Government’s U-turn on super-casinos is that Manchester won the bid to build Britain’s first-ever super-casino precisely because the city council pledged to put in place a social support network of education and research, coupled with professional support for problem gamblers. There are conflicting views on whether super-casinos provide meaningful levels of additional local employment and whether they bring wealth or take money out of the local community. The Manchester project was to test this out with the best available social safeguards.

Whatever the Government does about super-casinos – and my instinct is that, sooner or later, public demand will bring super-casinos to Britain – problem gambling has significantly increased in this country according to the most recent British Gambling Prevalence Survey. However, this can be minimized through education, prevention, and intervention. Instead of making decisions about a solitary super-casino in Manchester, the Government should act to minimize the risk of gambling addiction on a practical level by introducing controls on industry practice, education in schools and elsewhere, and treatment on the NHS for those who get into difficulty. And let the gaming industry – rather than the taxpayer – foot the bill.

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

Further reading

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. Available at: http://www.gamblingcommission.gov.uk/PDF/British%20Gambling%20Prevalence%20Survey%202010.pdf