Gambling Related Harm: A review of the scope for population health intervention Allison Thorpe Charis Miller, Knowledge Services, NHS Health Scotland 30 June 2014 0 Contents Background to Review: Gambling in Scotland ............................................................................................ 3 Methodology and Research Questions .......................................................................................................... 4 Quality of evidence and limitations of this review ......................................................................................... 5 Findings: ............................................................................................................................................................. 6 Motivations for problem gambling ............................................................................................................... 6 Identifying problem gambling ................................................................................................................... 8 Associations of gambling with other health conditions and lifestyle behaviours ............................... 16 Alcohol use ............................................................................................................................................... 16 Tobacco use ............................................................................................................................................. 17 Substance abuse ..................................................................................................................................... 18 Mental health ............................................................................................................................................ 18 Aggression ................................................................................................................................................ 19 Adolescent gambling ...................................................................................................................................... 19 Prevalence and gambling behaviours .................................................................................................. 19 Online gambling ....................................................................................................................................... 20 Health risks associated with online gambling (not age specific) ...................................................... 20 Contextual Factors .......................................................................................................................................... 21 Familial exposures ...................................................................................................................................... 21 Working in the Gambling Industry............................................................................................................. 21 Prison health ................................................................................................................................................ 21 Exposure to gambling marketing .............................................................................................................. 23 Social marketing and gambling ................................................................................................................. 25 Discussion ........................................................................................................................................................ 25 What is effective in addressing problem gambling behaviour? ............................................................ 25 Primary prevention interventions .............................................................................................................. 27 Improve assessment and surveillance ................................................................................................. 27 Improving understanding of barriers to seeking help ......................................................................... 27 Informing intervention design through improving understanding of differences in health seeking behaviours ................................................................................................................................................ 28 Public Education ...................................................................................................................................... 29 Investigate the potential of applying learning from other areas ....................................................... 32 Secondary Prevention interventions ......................................................................................................... 32 Support skills development initiatives .................................................................................................. 32 Self Exclusion .......................................................................................................................................... 34 Tertiary Prevention ...................................................................................................................................... 34 Internet based approaches to address problem gambling ................................................................ 34 1 Inequalities and Gambling ............................................................................................................................. 35 Areas where additional research may be helpful ....................................................................................... 36 Role of regulation as part of an overarching risk and prevention strategy ......................................... 36 Needs Assessment ..................................................................................................................................... 37 Concluding remarks ........................................................................................................................................ 37 Appendix 1: Search Strategy ........................................................................................................................ 38 Appendix 2: Abbreviations utilised in report ............................................................................................... 45 Appendix 3: Overview of literature ............................................................................................................... 46 References ....................................................................................................................................................... 75 2 Background to Review: Gambling in Scotland In recent years, the focus on gambling behaviour and gambling related harm has intensified as an area of public health interest. As gambling has become more widely accessible, the issue of gambling behaviour has become an increasingly important area to consider for population level interventions. It is not a homogenous set of activities, but rather a generic term covering a broad range of behaviours and activities. Arguably, many gambling activities have become increasingly normalised, with deregulation leading to the opening up of new opportunities to gamble, multimedia platforms opening up opportunities for interactive gambling, alongside the development of the national lotteries, television advertising, and many online services and programmes opening up knowledge of gambling opportunities to new markets for the provision of gambling services. Unsurprisingly, increased accessibility of legalised gambling opportunities has been accompanied by increased interest in gambling related harms, individual, familial and societal costs. In addition, potential problems are emerging associated with the compulsive behaviours associated with online and computer gaming, which are increasingly conflated with real time gambling. Despite the broad range of new, emerging, and existing challenges, arguably, however, gambling issues lack the salience of ongoing high-profile topics such as the economy, health care, education and the environment, and as such achieve lesser public recognition. (Smith, Schopflocher et al. 2011) In January 2007, the British Medical Association published a report recommending that those experiencing gambling problems should receive treatment via the National Health Service (NHS). However, there is some evidence that treatment provision remains at best patchy, with presentation with other co-morbid disorders being a key factor in access to treatment through the NHS. (Rigbye and Griffiths 2011) This report focuses on the scope for population level intervention to address the challenges associated with problem gambling behaviours and gambling related harms. Definitions of problem gambling vary across the literature, with a range of terms used to describe problematic gambling, including: compulsive, pathological, disordered, level 2 and level 3, neurotic, at-risk, problem, excessive, addicted, with attempts focusing on differentiating between behaviour which is controlled, recreational, and social, and behaviour which results in significant detrimental consequences to the person gambling and to others. Such definitions tend to suggest that gambling is a problem that one has, or does not have, suggesting that those who exhibit problem gambling symptoms are in some way different from the general population, with minimal attention focused on the consequences