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A pair of handsome male celebrities invite me to click on a game based on their TV show, next to five glamorous young women promoting blackjack, and surrounded by animated slots with names such as Mega Moolah, Lotsa Loot and King Cashalot.
Welcome to the world of online gambling, where shiny young people appear to bet together for fun.
A few clicks away, there are more images: photos of eight young men, full of personality; one at the beach, another on a country walk, one playing the trombone in a band. Below the pictures are their names, dates of birth – and death.
All these men died by suicide as a direct result of gambling, according to their parents who have come together and founded the charity Gambling With Lives.
The men were all normal, bright, popular and happy with great futures ahead of them. Gambling was their only problem. They had not necessarily racked up massive debts – though some had – it was the insidious nature of what gambling had done to their hearts and their heads that caused their deaths, according to the charity.
Founders Liz and Charles Ritchie, whose son Jack took his own life last November aged 24 in Hanoi, Vietnam, say online gambling followed him wherever he went, with companies sending him inducements and invitations to play. Jack had been free from gambling for several months before his death – to be dragged back into the addiction proved too much for him. In his last letter, he wrote: “Point is, I'm past the point of controlling myself and I'm not coming back from this one.”
The contrast of the images is not lost on Dr Heather Wardle, Assistant Professor at the London School of Hygiene & Tropical Medicine (LSHTM), who specialises in gambling behaviour, policy and practice, and Gerda Reith, Professor of Social Sciences at the University of Glasgow, who have been collaborating on creating a definition of gambling-related harms to be used in British policy and practice.
Prof Reith said: “The idea of holding up this ideal of gambling to win money, to make life a little bit better and more exciting to people who often have very little money to start with, when what more often happens is that they end up losing money, getting into debt, and everything actually gets a lot worse – it’s tragic. There’s a huge human, as well as social and economic, cost to this.”
Concern over problem gambling is a hot topic. In November 2018 the Gambling Commission, which regulates gambling providers, revealed that 1.7% of children are classed as having a gambling problem.
The Commission’s study suggested that 14% - equivalent to 450,000 - children aged 11 to 16 bet regularly, more than have taken drugs, smoked or drunk alcohol.
“There’s a huge human, as well as social and economic, cost to this.”
Prof Gerda Reith
Prevalence of gambling in the UK among 11-16 year olds in 2018
Shortly before the release of that report, there had been renewed concern over the harm caused by Fixed Odds Betting Terminals (FOBTs), electronic gambling machines found in betting shops where punters can bet £100 stakes every few seconds. The roulette versions have been dubbed the ‘crack cocaine’ of gambling.
The Government was forced into an embarrassing climb-down over cutting stakes on FOBTs from £100 to £2 in April rather than October 2019 – the delay of which sports minister Tracey Crouch had resigned over two weeks before.
For it is the Department of Digital, Culture, Media and Sport that is responsible for gambling. Many now argue it is not a sporting or leisure problem, but a health issue. The Labour party’s deputy leader Tom Watson MP said recently that problem gambling is a hidden epidemic and must be treated as a public health emergency.
This was welcomed by Dr Wardle. She believes the widespread harms of gambling, not just for the individual taking part but their families and wider society, have been hidden for too long. It is, she says, disruptive and extremely challenging.
But because its harms are not currently quantified, it’s easy for policy makers not to take the consequences of problem gambling seriously enough.
She says there’s a sense that people get into problems, lose a bit of money and it’s considered their own fault, an individual’s problem with no understanding of the severe and wider nature of the consequences.
Dr Wardle said: “Until you have more of that recognition, you don’t get adequate policy responses, or a strategic approach from government as to what you’re going to do on this issue because there is, arguably, a tendency to err on the side of protection of people’s liberty to engage with this activity, rather than prevention.”
Prof Reith agrees. “An individual with gambling problems undoubtedly needs help from professionals, but we also need to look at the knock-on effects on their families, their relationships, on debt,” she said.
“Debt has massive ripple effects in the economy. At the extreme end it can tear families apart, people can lose their homes. On a lesser scale, it means relationships and trust can be eroded, kids go without that school trip, or that extra Christmas present. The erosion of money and of trust just makes life that bit harder and more difficult.”
These ripple effects can be extensive and enduring. She adds: “These things don’t just go away after the gambling’s ‘cleared up’, so to speak. The broken relationships, the credit default, and maybe the criminal activity that people engage in. Whether it’s borrowing money off friends that they never pay back, or defrauding their work - these things have long term impact.”
Earlier this year as deputy chair of the Responsible Gambling Strategy Board, Dr Wardle led an expert group with Prof Reith and others to propose a formal definition of gambling-related harms.
The resulting document published in July Measuring gambling-related harms: A Framework For Action stated “gambling-related harms are the adverse impacts from gambling on the health and wellbeing of individuals, families, communities and society”. It sounds simple, but the authors say it’s needed to encourage a change in the way policy makers, politicians and wider society think about gambling in this country.
There have been positive responses from the Gambling Commission, people who work with problem gamblers, and problem gamblers themselves. Government has been less vocal, but Dr Wardle is cautiously hopeful the message is getting through.
Public Health England, she says, has been charged to think about problem gambling, with proposals for a cross-departmental group between the Department of Health and Social Care and the Department of Culture, Media and Sport. “There are positive conversations happening with the NHS,” she said. “There’s going to be small incremental changes which hopefully over time will add up to something bigger.”
The expert group will next explore the impacts on young people specifically and attempt to estimate the cost of gambling-related harms to society and the economy.
Gambling over time
It is instructive to look at how gambling has been perceived by society and treated by the medical profession in comparison with alcohol and drugs, which have become such significant public health issues in the UK.
They have long been lumped together. At the beginning of the last century, Joseph Rowntree, the founder of the Joseph Rowntree Foundation social policy charity, identified gambling as one of seven social evils (the others being poverty, war, slavery, intemperance, opium and impurity).
Much of the criticism was moralistic and quasi-religious in tone, wringing hands over poor people wasting their money when they should be working hard and saving. The same criticisms were used by the temperance movement - drinking was bad, but especially when the poor did it.
Around this time, the idea developed that excessive alcohol use was a disease to be treated. This was partly because of the development of the medical profession and specialties including ‘inebriety’ – the term used to describe the disease where someone was inebriated, due to alcohol or drugs.
Prof Virginia Berridge, a social historian at the London School of Hygiene & Tropical Medicine, says many doctors were frustrated by the ‘revolving door’ of excessive drinkers being criminalised for being drunk and disorderly and thrown into prison for a month, only to be released and repeat their behaviour.
“The only way they could change things for the better was to establish a disease view of the use of alcohol to excess so they could introduce a treatment structure,” she says.
During the First World War the word ‘addiction’ started to be used over concerns about cocaine in the West End of London, and ‘alcoholism’ became the preferred term for excessive alcohol use.
In the 1950s the term ‘habituation’ was used by the World Health Organization (WHO) to describe being accustomed to illicit drugs rather than addicted, and then in the 1970s and 1980s ‘dependence’ was introduced by the WHO as a concept to unify alcohol, drugs and smoking.
“Gambling, and the marketing of gambling, has become really normalised and accessible. This is unsustainable and is causing harm, particularly to vulnerable groups.”
Prof Gerda Reith
It was around this time that gambling first became included in this arena in the UK. One of the pioneering centres of research on dependence was the Addiction Research Unit at London’s Institute of Psychiatry, where psychologist Jim Oford worked. He wrote Excessive Appetites, one of the first academic discussions that discussed gambling, alongside the usual ‘addictions’ as well as eating excessively and sexual activity.
“Psychology as a discipline was very important in broadening the idea of what was a compulsive behaviour that people were doing against their own best interests,” says Prof Berridge.
In modern times, according to Prof Reith, problem gambling has been medicalised as a psychological flaw; a mental health problem that affected individuals who were supposedly too impulsive to control themselves. It was incorporated into the American Psychiatric Association’s internationally used Diagnostic Manual of Psychiatric Disorders in those terms in the 1980s.
The early edition used the term ‘pathological’ gambling but in 2013 it was changed to ‘gambling disorder’ and placed in the category of behavioural addictions.
Social scientists and others believe that following this medical model overlooks the much more extensive and unseen harms that widespread gambling can cause.
Legislation and liberalisation
Despite this increased recognition from the academic community, Dr Wardle finds it interesting that during the 20th century, while alcohol and drugs remained problems that society was concerned about, there has been ‘collective amnesia’ about gambling, which was hidden away in the back streets through strict regulation.
This changed once successive governments liberalised the laws. The introduction of the National Lottery in 1994 paved the way for the 2005 Gambling Act. Once the act came into force in 2007 gambling was more visible through open advertising; putting it online made the activity even more prominent and available.
Prof Reith says the new act was framed as a modernising of attitudes in line with new technologies, but in fact politicians have permitted more and more intense and hard forms of gambling and allowed it to be widely promoted. “First of all into casinos, and then out of casinos into the high street, onto the internet,” she said. “Gambling, and the marketing of gambling, has become really normalised and accessible. This is unsustainable and is causing harm, particularly to vulnerable groups.”
Dr Wardle does not believe the public was clamouring for liberalisation of gambling in the early 2000s. “It was a really deliberate attempt by those in power to reposition gambling,” she says. The pendulum has now swung: today’s Labour party has vowed to create a new Gambling Act with prevention of harm as a core value.
Rise in gambling advertising
The legislators in 2005 were likely to have been influenced by Australia, where electronic gaming machines had been introduced in the late 1980s. The country soon became dependent on gambling as a form of state finance.
Martin McKee, Professor of European Public Health at the London School of Hygiene & Tropical Medicine, says that’s why better regulation – limiting the appeal of gambling - is needed to prevent it ever becoming a taxation cash cow in the UK.
“There's a real danger with what are called sin taxes, in that you get dependent on them,” he says. “And then you have a conflict of interest because you're happy to see the activity go on because you're generating money for public health.”
Counting the cost of gambling
But before Government commits to funding prevention strategies in the UK, the problem needs to be quantified. Dr Wardle sees a particular parallel with alcohol in that most people drink, many enjoy it, but some will get into difficulties.
The difference is that the harms are much more visible. People attend hospital with issues from drinking and there are records of deaths related to alcoholic-related liver disease, which can be quantified. With gambling, both the activity and the harms are hidden. GPs may see patients with poor physical health and mental health issues and have no idea that gambling is underpinning the symptoms.
And while suicide is a shocking way of linking gambling with deaths, Dr Wardle believes we have no way of knowing how many other deaths are indirectly associated.
She said: “We’ve got no assessment of gambling-related morbidity and that, for me, is crucial. It may well not be at the same level of alcohol, but that doesn’t make this any less of a public health challenge.”
Prof Reith believes there are similarities between gambling and tobacco, alcohol and fast food, and she draws the link in her new book Addictive Consumption: Capitalism, Modernity and Excess. In the same way we are used to the concept of obesogenic and alcogenic environments, she believes we now live in an ‘aleatory’ environments, from the Latin ‘to gamble’, in which gambling is pervasive and widespread.
She says in the colonial era, sugar, tea, coffee and tobacco were seen as deeply problematic, likened to drugs and often criticised, regulated or outlawed. “As they became sources of massive profit and revenue, they were liberalised, accepted and normalised,” she said. “There are some similar trends going on with gambling.”
But waves of acceptance, she says, eventually go full cycle and today, a focus on health risks has stimulated increasing regulation again. Now there’s an understanding that consumption of certain things such as sugar, tobacco or alcohol brings problems in terms of obesity and cancers and addictions.
“We’ve got no assessment of gambling-related morbidity and that, for me, is crucial. It may well not be at the same level of alcohol, but that doesn’t make this any less of a public health challenge.”
Dr Heather Wardle
According to Prof Reith, there’s also increasing awareness of industry tactics: the production and marketing of potentially dangerous forms of consumption is driven by the profit motive, and politicians are often lobbied by those industries in ways that mean they often avoid state regulation.
The other comparison with food is that it’s not just whether you eat it, it’s how you eat it. With gambling, there’s a sliding scale of potential harm, with lotteries considered the ‘soft’ forms and electronic gaming machines and online slots ‘hard’.
But it’s not only that some types are intrinsically less harmful. Harm depends on the frequency and speed at which people play certain games; the amounts of time and money they lose, and on how their losses affect other people.
All types of gambling, she says, have the potential to be harmful if you can’t afford the losses. “Gambling isn’t necessarily harmful in itself, it’s losses relative to income that’s important.”
Prevalence of gambling in the UK (2010)
Who is harmed the most?
In order to provide prevention and treatment strategies, it’s important to know who’s at risk. Anybody can develop a gambling problem, but like other public health issues, it is ‘socially patterned’: people who live in more economically deprived circumstances are all more likely to experience harm.
This is because loss of money affects poor people the most. Gambling problems are far more intensive when people are living on the bread line. From a public health perspective, gambling is very much an activity that reinforces health and social inequalities.
Surveys of gambling behaviour consistently show two to three times more men are problem gamblers than women, but Dr Wardle believes this could be because the clinical criteria and definitions of problem gambling were originally based on conversations with men.
Women do choose to gamble in different ways from men, and traditionally it was thought that women preferred games of chance such as the lottery, scratch cards, or fruit machines, whereas men choose games of skill such as betting or poker. Prof Wardle questioned this theory in her PhD.
“There is no biological reason that women choose a game of chance over a game of skill. It is completely socially conditioned,” she says. “When the legislation on bookmakers was introduced in the 1960s, the politicians created deliberately austere, unlikable places to try and put women off going to them. Bingo halls were put in places women already went such as former cinemas.”
The fact that women do enjoy skilled gambling activities was shown in World Cup betting statistics, which included more bets from women this year. Dr Wardle said: “It seems entirely obvious to me that if you change the circumstances in which gambling is provided - and you now have online gambling where women can do it in a sort of safe space - then of course women are going to be engaged.”
Young people are also an at-risk group and the risk of harm is increasing. The Gambling Commission 2018 report says 1.7% of 11-16 year olds are problem gamblers, compared with 0.9% in 2017, and 2.2% ‘at risk’, up from 1.3% in 2017.
According to Dr Wardle’s latest published research problems among young people may be underestimated.
This generation is growing up with a fundamentally altered relationship to gambling and a fundamentally altered relationship to technology. Because gambling happens in cyberspace it is particularly attractive to them.
As a result, her current area of research, backed by a Wellcome Fellowship, is to understand youth gambling behaviour and its relationship with changing technology.
She’s currently recruiting 14-18 year old school children for focus groups and doing in-depth interviews with 30 young online betters, mapping how technology has shaped their gambling career, followed by a survey of 14- to-24-year-olds.
Cyberspace and mobile gambling
The ability to gamble on mobile phones has caused another radical change. The recent Gambling Commission study showed 13% of 11-16 year olds have ever played online gambling-style games (which are often free to play and offer no cash prizes), with more than half of these (54%) playing via apps on smartphones or tablets.
Smartphones can be addictive in their own right; and when appealing technology is embedded on an appealing device enabling an appealing activity such as gambling, Prof Reith believes it’s creating a perfect storm.
“A lot of policy circles are still coming to terms with the fact that gambling happens on the internet,” says Prof Reith. “Actually the biggest growing sector is mobile, and there’s very little research on this.”
She believes mobile technologies make gambling more immediate, more intense, and a lot more personal. “This device that I can hold in my hand and take everywhere with me, is also the device I can gamble on. And it’s not just the device that I see gambling on, I also gamble through it as it holds my bank details.
“It’s very immersive and of course it’s going to be hugely appealing for the generation who’ve grown up with these things.”
Working with industry?
The first step towards change, according to Dr Wardle, is recognition of gambling by the government as a public health issue, followed by legislation and regulation, as has happened in New Zealand. Dr Wardle says at the bare minimum, gambling should be a co-owned issue between the Department for Digital, Culture, Media, and Sport and the Department of Health and Social Care.
But Prof McKee says it is vital that Public Health England does not fall into the same trap of working with The Senet Group as it did with Drinkaware, an alcohol education charity that receives funding from the industry.
The Senet Group, an organisation promoting what it claims are sensible gambling standards, was created by four of Britain’s leading gambling companies – William Hill, Ladbrokes, Coral and Paddy Power – in response to public concerns on gambling, and gambling advertising in particular.
In September Prof Sir Ian Gilmore, a senior adviser to the UK government on alcohol policy, quit after NHS England entered into a partnership with the drinks industry, which he argued would undermine efforts to protect public health.
He said he and others ‘strongly believe’ the alcohol industry should not have a role in providing health information to the general public.
Prof McKee agrees the same goes for gambling. He said: “The lesson of Public Health England’s engagement with Drinkaware sends out a very clear signal that any link with them would be equally unacceptable.”
Advertising bans and the precautionary principle
Prevention strategies may include bans on advertising, particularly around sporting events, engaging the precautionary principle – that in the case of serious threats to health, scientific uncertainty should not be used as a reason to postpone preventive measures.
Prof Reith wants a major shift on gambling advertising of the type that has been so effective for smoking. “Could you imagine tobacco being advertised the way gambling is advertised now?’ she asks. “When you present that scenario to people, they tend to recoil.”
Australia leads the way in responsible gambling initiatives such as banning advertising at live sports events and immediately before and after transmission as well as installing safety features on some electronic gaming machines, with set limits on how much you can play at any one time, and maximum prize caps.
Belgium has also banned advertising around live sports events while Italy has just announced a blanket ban on all gambling advertising, with a minimum £44,000 fine. Conservative peer Lord Chadlington, formerly Peter Selwyn Gummer, who has been campaigning on UK gambling policy, has written starkly: “Italy has recognised the severity of the problem and acted decisively. Why can’t we?”
Hard cash and a Statutory Levy
After legislation, the next step is well-funded prevention strategies.
But all these initiatives cost money.
Currently, industry voluntarily contributes 0.1% of gross gambling industry profits - around £10 million a year - for research, education and treatment, and the vast majority of it goes on treatment.
Dr Wardle says this is a ‘pittance’ compared with the costs associated with gambling and says it is hard for services to plan strategically when the future annual funding budget is unknown.
Instead she and many others support a statutory levy of at least 1%. Other high profile supporters include the Labour party, Gambling With Lives and Lord Chadlington.
He cites Gambling Commission figures published in 2017 (co-authored by Dr Wardle) that there are 430,000 problem gamblers in the UK and a further two million people are in danger. He wants the £130 million generated from a 1% mandatory levy to be directed to a new independent commission executing and monitoring a harm-reduction strategy.
That strategy should include a nationwide programme backed by the Government to help those already addicted, those at risk of gambling-related harm and to support affected families.
“There is a real need to raise the terms of debate and generate more solid knowledge about what gambling is, what role it ought to have in our lives and the levels of protections we’re willing to place on it”
Dr Heather Wardle
More research is needed particularly on the suicide risks and impact on children, of the type being done by researchers at LSHTM. “Good and effective law is based on robust information,” he says.
There certainly appears to be an appetite for this – Prof Berridge was teaching PhD students on addiction recently. “I expected them all to be working on drugs and alcohol but the majority were working on gambling, it’s obviously a coming area,” she said.
With growing concerns over the harms gambling can cause, this is a critical moment for the policy and research world to step up to the challenges. The title of the 2018 GambleAware annual conference in London is Reducing gambling-related harms: Diversity.
“There is a real need to raise the terms of debate and generate more solid knowledge about what gambling is, what role it ought to have in our lives and the levels of protections we’re willing to place on it,” Dr Wardle said.
Simply highlighting the increasing noise around the issues may not be enough to trigger action – but it’s a start.
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