Gambling as a public health issue

guest post by Magda in my team

Short summary – below

Links to more comprehensive document set at bottom

Problem Gambling in Sheffield

Why is this an issue?

Problem gambling (gambling behaviour that is frequent, repeated, dominates lives and disrupts personal, family, or vocational pursuits) is a relatively low prevalence and stable problem in the UK. However, problem gambling is associated with a range of harms including health, divorce, unemployment, bankruptcy, domestic violence and inter-generational impacts for children of problem gamblers. For this reason, problem gambling there are calls for problem gambling to be viewed as a public health issue alongside other addictions such as tobacco, alcohol and drugs.

Around 1 in 20 people aged 16+ in general practice report problem gambling at a low or moderate severity.

Problem gambling is seen more often in those who are already vulnerable due to young age, mental illness, and other addictions. Young, economically inactive men are particularly vulnerable.

New arrivals, un-used to the widespread availability of legal gambling in the UK, may be more vulnerable to developing problems. Where people have mental health and gambling problems, in most cases, the mental health problems precede the problem gambling, but in 25% of cases mental health problems are first reported after a person develops problem gambling.

What is nature of the thing?
There are currently 107 premises in Sheffield licensed for gaming or gambling including Bingo, Casinos, Betting offices, track betting. This does not include online gambling which is more strongly associated with problem gambling.

Gambling premises are often clustered in deprived neighbourhoods, near sources of credit such as payday lenders. This particularly impacts those who may already be financially excluded. The area around Fitzalan Square in Sheffield is an example of this with three betting shops, an adult gaming centre, a bingo hall and a cheque cashing/pawnbrokers shop in close proximity. 44% of betting shops in Sheffield are in areas that are amongst the 20% most deprived in England. Where there is geographical proximity to gambling premises then problem gambling is more evident, but this link is not necessarily causal.

Gambling-related debt is more likely than other types of debt to lead to relationship difficulties and breakdown with self-reported average debts of problem gamblers ranging from £17,500-60,000.

How to address the issue?
The strategies for dealing with problem gambling include:
– Addressing the gambling products
– Addressing the gambling environment
– Addressing wider determinants of gambling related harm (vulnerabilities)
– Addressing gambling related debt
– Addressing the addiction through treatment

Addressing the gambling products: For young people (aged 11-15) “fruit machines” are one of the most popular formal gambling activities. For adults problem gambling prevalence is highest for: spreadbetting (21%); poker games and betting on events or sports (both 13%); betting with a betting exchange (11%); with playing machines in a bookmakers such as Fixed Odds Betting Terminals (7%). Online gamblers are more likely to be problem gamblers than those placing bets in premises. FOBT have received national and local attention because high stakes and high frequency play mean large sums are lost very quickly.

Legislation to limit the number of FOBTs in any one premise was circumvented by operators opening multiple clustered premises.

Address environmental factors: Local Authorities may use planning powers (Article 4 directions under the Town and Country Planning Order 1995) to restrict proliferation and clustering of gambling establishments and/or license conditions where granting a license would impact negatively on the three Gambling Act 2005 licensing objectives.
Addressing wider determinants: Addressing social determinants such as neighbourhood deprivation and youth unemployment through regeneration and community development.

Identify: Recognising individual risk factors, the “profile” of a likely problem gambler may enable identification through selective screening and early intervention. There are simple screening tools, which can help identify problem gamblers. These include self-administered tools. The Royal College of GPs recommends the 2 question Lie/Bet tool for GPs who are well placed to identify problem gamblers in routine practice.

Treat: Clinical treatments that are effective for problem gambling include psychosocial interventions (Cognitive Behavioural Therapy) and pharmacological interventions (using drugs which work with other addictions to limit pleasure and reward). One third of people will get better on their own with no treatment. There has been criticism of industry-funded and commissioned treatment.

As problem gambling is highly co-morbid with a range of mental health conditions and addictions it is likely that problem gamblers are already receiving treatment from those with relevant clinical skills so where possible clinicians could concurrently address problem gambling.

Refer: Peer support groups are available in Sheffield including Gamblers Anonymous and SMART recovery. There is one specialist NHS clinic for England and Wales, the National Problem Gambling Clinic.

Address debt holistically as part of wider issues: Addressing debt in isolation tends to be detrimental. Industry and user-led mitigation and self-help measures such as self-exclusion, time-limits or cash-limits have low take-up, are often breached, and there is little evidence of effectiveness.

So What?
Problem gambling is more than a financial inclusion issue or a public health issue, it becomes a health inequalities and social justice issue about why the most vulnerable in society are most exposed to products and environments which are likely to cause them harm.

Local Authorities can use their powers (through planning and licensing) to promote healthy neighbourhoods, not harmful neighbourhoods. The virtual sphere is out of Local Authority control, so there will always need to be services and interventions on the individual level, not just the environmental level to support problem gamblers as individuals.

NHS commissioners can empower clinicians to treat problem gambling as a concurrent condition with other mental health problems and addictions. GPs are very well placed to identify problem gamblers and intervene early. Other providers working with young people, debt, domestic abuse, offending also have opportunities to identify problem gamblers. The industry itself can adhere to voluntary codes to enable self-exclusion, time and cash limits.

Want to know more?

A4 Summary (above)
Problem Gambling A4 Summary

Full documment
Gambling evidence summary v5

Problem Gambling Evidence

suggested audit criteria
Problem Gambling Service Audit Criteria v2

Elsewhere in the world, the thinking seems similar

It’s also worth reading this piece from Australia

There too they are finding that many like to frame it as a problem of a tiny number of highly addicted gamblers.

Whilst this is convenient for the industry (sound familiar – alcohol industry Playbook) it sort of ignores the more holistic and likely more effective approach of whole system, whole population approaches

“Focusing only on problem gamblers leaves the vast majority of gamblers and others with a false sense of security.”

Also education and awareness raising is characterised as about as effective as a chocolate teapot.

“This is not an issue to be addressed simply with a few ‘gamble responsibly’ statements.”

See here

“The prevention paradox applies to gambling, we should monitor harm, learn more about ‘recreational’ and low risk gamblers who account for the greatest proportion of harms – @m__browne #IGC2018”

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