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
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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
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