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There are a variety of resources on the Internet that can help a problem gambler get their gambling under control. There are also many 24-hour help lines that are designed to offer counseling, referrals and someone to talk to about problem gambling. These resources are listed below. Benton Country Health Department offers three treatment options. Gambling is a highly profitable commercial activity, with providers including international corporations and governments. However, there is growing international recognition that gambling is a source of serious harm, and that there is inequity in the distribution of this harm, which has led to demands for action to protect public health. These concerns are reflected in the recent report from. Place gambling within a public health framework by examining it from several perspectives, including population health, human ecology and addictive behaviors; 3. Outline the major public health issues about how gambling can affect individuals, families and communities; 4. Propose an agenda for strengthening policy, prevention and treatment. Gambling is addictive so it can easily get out of hand. It can harm you in many ways – it can lead to ill health, emotional and psychological distress, financial harm, poor performance at work or study, relationship problems and crime.

Prevention of harms related to gambling requires investment in population based approaches, say Heather Wardle and colleagues

• Current approaches targeting affected individuals substantially underestimate the harms of gambling

• Gambling places a major burden of harm on individuals, communities, and society

• Harms from gambling are generated through a range of political, legislative, commercial and interpersonal actions

• Public health approaches to reduce harms related to gambling should encompass a range of population based approaches supported by regulation, legislation. and funding

In 2017 the gambling regulator for Great Britain, the Gambling Commission, described problem gambling as a public health concern (box 1)³ and emphasised the need to increase protection from harm.⁴ In 2018 the Faculty of Public Health released a position paper arguing for the introduction of harm prevention measures, underpinned by legislation, targeted at the whole population.⁵ The Labour Party recently shared plans for a radical overhaul of legislation to reduce the harms associated with “Britain’s hidden epidemic.”⁶

Box 1

• Gambling encompasses a broad range of activities, ranging from the National Lottery to casino games, slot machines, and online betting

• Around 58% of adults in Great Britain gambled on at least one of these activities in the past year

• Approximately 0.7% of adults (about 340 000 people) in Great Britain are problem gamblers and a further 1.1% (about 550 000) are at moderate risk of harms related to gambling

• Online gambling—on casino or slot style games and sports betting—is the largest growth area in the sector, accounting for over a third of the market. There are over 33 million active online gambling accounts in Great Britain

• The prevalence of online gambling has increased from less than 1% in 1999 to 9% in 2016, with many online gamblers holding multiple accounts. This makes online gambling as popular as traditional betting on horses and more popular than playing slot machines or visiting casinos

• 14% of children aged 11-16 have gambled in the past week, with around 55 000 reporting problems from their gambling behaviour

Despite these announcements, commercial gambling in Great Britain, as in many other jurisdictions, is still not legislated as a public health problem. Simply stating that gambling is a public health concern is not enough. It must also be treated as one by policy makers through the development and implementation of a fully realised and sustainably funded strategy for preventing harms among the population.

Understanding gambling related harms

The first step towards developing effective harm prevention policies lies in identifying the nature and scale of the issue. Until recently, the health effects of gambling were largely understood in terms of individual pathology, based on the categorisation of clinical symptoms or behaviours, such as preoccupation with gambling, failed attempts to stop, increasing tolerance for gambling or gambling to escape problems, using specified diagnostic criteria as set out in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.⁷ But this perspective identifies only a small minority of the population as having gambling problems. This, together with neoliberal ideas of health promotion that emphasise individual responsibility for health choices, has focused policy attention on the treatment of a minority of “problem gamblers” and the promotion of “responsible gambling” and self control. This approach is supported and promoted by industry, a powerful actor in this system. As with discussions around other products harmful to public health, such as processed foods and alcohol, focusing on the individual aligns with industry interests by shifting regulatory attention away from the products and commercial practices that generate harms and from the broader policy measures that would restrict and regulate their availability.

We need a systematic reframing of the issue that recognises the major burden of harms that gambling places on not only individuals but also communities and society¹¹¹² and that acknowledges the role of commercial, policy, and regulatory forces in shaping the environment in which these harms occur. Then we need a shift in policy that focuses on the broader effects of gambling on individuals, families, friends, communities, and society. These effects include financial problems, relationship breakdowns, abuse or neglect of partners and children, and adverse childhood experiences that disrupt relationships and education during periods of cognitive and social development.¹³

Harms related to gambling reflect social and health inequalities, with negative effects unequally distributed among economically and socially disadvantaged groups and are commonly associated with a range of mental and physical health comorbidities.¹⁵ At its most severe, gambling can contribute to loss of life. Research from Victoria, Australia, estimated that around 2% of suicides between 2010 and 2012 were related to gambling.¹⁶

Broadening our focus beyond problem gambling reveals the true scale of its negative effects and has implications for estimating its economic and social costs. Harms affect a much larger proportion of the population than just those who might be defined as problem gamblers: for every one person with problems, an estimated five to 10 people are adversely affected.¹⁷ In Australia, the burden of harms that gambling places on health and wellbeing is estimated to be of similar magnitude to major depressive disorder or alcohol misuse and dependence.¹¹ In Great Britain, conservative estimates of social costs range between £200m (€230m; $260m) and £1.2bn a year, and these are likely to be considerable underestimates.¹⁸

Epidemiological evidence indicates high levels of “churn” in and out of problematic and at-risk behaviour. In Britain, a follow-up study of highly engaged gamblers (individuals with loyalty cards for major bookmakers) showed that around one in three people defined as non-problem, low risk, or moderate risk (according to their scores on the Problem Gambling Severity Index) had increased their problem gambling scores when interviewed one year later.¹⁹ Longitudinal research in Australia found that the number of newly identified problem gamblers accounted for half of the prevalence rate, signifying high degrees of movement in and out of this kind of behaviour.²⁰ Such volatility reinforces arguments for targeting resources towards harm prevention to avoid escalation.

Harms from gambling affect health and wellbeing and, even at low risk levels, contribute to a loss of quality of life similar to the long term consequences of a moderate stroke, moderate alcohol use disorder, and urinary incontinence.¹¹ These low level harms arguably contribute more to aggregate social costs than those from people gambling at problematic levels because of the greater population numbers experiencing them. Australian research found that up to 85% of the harms caused by gambling came from those who were not categorised as problem gamblers.¹¹¹² This indicates that current calculations of the social costs of gambling in Britain, which focus only on costs generated by the small number of individuals categorised as problematic, are likely to be major underestimates. As such, there are likely to be considerable, but as yet unquantified, burdens placed on the health, welfare, and judicial systems dealing with the consequences of these harms.

A recent report for the Gambling Commission has drawn on the broader approaches newly adopted in Victoria, Australia, and New Zealand to produce a pragmatic definition of gambling related harms intended to guide policy formation (box 2).²¹

Box 2

• Gambling related harms are the adverse impacts from gambling on the health and wellbeing of individuals, families, communities and society

• These harms are diverse, affecting resources, relationships, and health, and may reflect an interplay between individual, family, and community processes. The harmful effects of gambling may be short lived but can persist, having longer term and enduring consequences that can exacerbate existing inequalities

Broader understanding of the determinants of harms

Shifting the focus away from harms as being generated by a small number of individuals who are experiencing a clinical disorder brings with it a reconsideration of the broader determinants of those harms. An interplay of individual, social, and environmental processes is known to contribute to many illnesses.²² Around 50% of global variation in health status is attributable to social and environmental context, and gambling is unlikely to be different. Those who gamble (harmfully or not) are embedded within an environment shaped by commercial, legislative, regulatory, and cultural forces that determine the availability and accessibility of gambling products and venues, as well as the advertising and promotion of gambling on a wide scale (fig 1). Since implementation of the Gambling Act 2005 the scale and sophistication of industry marketing has increased in both land based and online contexts.²⁴ As with alcohol and unhealthy foods, commercial gambling is sustained and promoted by a powerful global industry in ways that not only make it more widespread but also shape how we think about appropriate policy responses to the health effects of its products.

The social-ecological model for gambling. Factors that influence the potential experience of harm.

Implications for policy

Recognising the wider environmental and commercial determinants of harm requires a re-orientation of policy and practice. Effective preventive action needs to go beyond existing interventions aimed at individuals, which have largely relied on industry led measures targeted at high risk individuals, for example through the development of algorithms to detect harmful levels of play (in online settings) or the voluntary setting of time and money limits. As a recent review notes, prevention activity in Britain has been underspecified and is inadequate.²⁵

Activities targeted at high risk individuals certainly form part of a coherent prevention strategy, but we also need legislative or regulatory measures that tackle the availability, licensing, advertising, and price of products. Other public health contexts show how measures that affect the whole population (such as smoke-free legislation in Britain) often have the biggest effect on behaviour change. Such measures should be used to regulate the design, licensing, and placement of gambling products, such as high intensity, high volatility, or high stakes gambling machines, throughout communities. They could be used to restrict the use of credit to gamble online or introduce mandatory affordability checks. They should also be used to curtail the scale and scope of industry advertising and marketing, particularly personalised marketing, through legislation.

Legislative and funding environment

Effective policy to reduce gambling related harms needs to adopt a broad focus, with strategic action planned and delivered to deal with the multifactorial determinants of health. This is well recognised for obesity, smoking, and alcohol consumption, but Britain has no government owned strategy for preventing harm from gambling.

British legislation currently seeks to balance enabling gambling with protecting (some) vulnerable people in a poorly specified way (box 3). Protecting vulnerable people from harm is a licensing requirement, but so too is “aiming to permit” gambling, and there is no guidance about the extent to which gambling could or should be curtailed in order to protect vulnerable groups. This contradiction needs to be tackled, and the protective mechanisms of the act strengthened.

Box 3

• The Gambling Act 2005 updated gambling policy and legislation in Great Britain

• The three licensing objectives in the act are:

  • preventing gambling from being a source of crime or disorder, being associated with crime or disorder, or being used to support crime

  • ensuring that gambling is conducted in a fair and open way

  • protecting children and other vulnerable people from being harmed or exploited by gambling

• Gambling is be treated as a valid leisure and recreational choice, meaning it can be freely promoted (subject to some limitations on advertising) and that licensing authorities have to “aim to permit” gambling as long as it is consistent with the three licensing objectives

• Policy responsibility for gambling has been held by the Department of Digital, Culture, Media, and Sport (DDCMS) since 2007

• Until March 2019, the National Responsible Gambling Strategy was produced by the Responsible Gambling Strategy Board, an independent advisory group to the regulator (Gambling Commission). From April 2019, it will be owned by the regulator. Neither DDCMS nor any other government department has responsibility for the strategy

• The National Responsible Gambling Strategy and its successor will continue to be funded through voluntary donations by industry unless a statutory levy on industry is invoked

In New Zealand, harm reduction is a legislative requirement, and the annual budget for the prevention of gambling harms is over $NZ18m (£9.3m; €10.7m; $12m) for a population of 4.7 million.²⁷²⁸ By contrast, in 2017-18 Britain had £8m for gambling research, education, and treatment for a population of 65 million; less than £1.5m was spent on prevention activity.²⁹ In Britain, this funding relies on voluntary contributions from industry. The costs of gambling are likely to considerably outweigh the benefits (in terms of tax revenues), indicating that it actually costs societies more to not systematically address gambling harms.¹² In Victoria, Australia, total tax revenue from gambling was $A1.6bn (£0.9bn; €1bn; $1.1bn) while estimated social costs were $AUS 6.97 billion, a net deficit of $AUS 5.4 billion.¹²

Funding for prevention and treatment of gambling related harms in Britain is woefully under-resourced, which needs urgent attention. The statutory power to impose a compulsory levy on industry exists, but successive governments have been unwilling to enact the levy. This is despite the industry regulator, their advisers, and even some industry actors themselves supporting a levy.⁴³⁰ This highlights why the broader system in which gambling policies are created and legislated must be considered.

Current policy responsibility for gambling is held by the Department for Digital, Culture, Media, and Sport rather than the Department of Health and Social Care, confirming that gambling is not considered a public health issue in the current legislative framework. Recent announcements around changes in the maximum stake sizes on so-called fixed odds betting terminal machines showed the political power of the Treasury, with the announced reduction in stake counterbalanced with an increase in remote gaming tax duty to ensure that the policy was cost neutral in tax revenue terms.³¹ This multiplicity of governmental actors, each with divergent or conflicting aims, slows the resolution of policy formulation and enactment.

If gambling is to be taken seriously as a public health issue then policy responsibility for prevention and treatment should lie with the Department of Health and Social Care, with input from other departments who deal with the harms of gambling such as welfare, justice, and education. Local authorities should also play a significant role given their responsibility for local public health policies, though their range of actions are constrained by the current legislative framework. The role of the NHS in this system should also be considered. Britain currently has only one NHS clinic for the treatment of gambling problems, funded through a charitable organisation that disperses industry donations, though this exemplar shows how these clinics can be a catalyst for broader prevention and awareness raising activities. The NHS long term plan, announced in January 2019, included commitments to expand the range of NHS treatment provisions for gambling, but what this means in practice and how it will be funded remain unclear.³⁴

Conclusions

Like other public health concerns, gambling is associated with wide ranging harms and disproportionately affects vulnerable groups in ways that contribute to and exacerbate existing social inequalities. It also imposes a large economic burden on society. The causes of harms are multifactorial, reflecting an interplay of individual, social, and environmental processes. Policy makers, especially those in central government, need to be aware of the potential health effects and substantial social costs of gambling and of the need to develop, fund, and implement strategies to prevent harm. These, crucially, should be evidence based and assessed for efficacy. In Britain, this policy does not yet exist, though the regulator is attempting to correct this. The policy and funding environment in which a coherent strategy for reducing gambling-related harms can be developed needs to be critically reassessed, along with the industry’s role in shaping existing practices. This requires a marked change in approach, and one that is long overdue, given that gambling harms are a matter of health equality and social justice.

Notes

Contributors and sources: This paper has been partially funded by Wellcome through HW’s Wellcome Research Fellowship in Humanities and Social Sciences (grant number 200306/Z/15/Z). HW is deputy chair of the Advisory Board on Safer Gambling an independent group that provides advice to the Gambling Commission on policy and practice. GR is a Professor of Social Sciences at the University of Glasgow. RDR is a professor of psychology at Bangor University and EL is a lecturer health promotion at Central Queensland University, Australia. The genesis of this article came from two reports produced by three of the coauthors: one a review of gambling and gambling policy conducted for Public Health Wales by RDR, HW, and others³⁵ and the other looking at the importance of measuring gambling related harms led by HW and GR.¹³ HW and GR acknowledge the contribution of pStephen Platt, David Best, and David McDaid to the harms report. Both reports draw on original work conducted by EL and colleagues, seeking to adapt and extend her research.¹¹ All coauthors have contributed equally to the production of this manuscript and approved the final submission. HW is the guarantor for this article.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. HW is supported by a fellowship from Wellcome (grant number 200306/Z/15/Z). Remuneration for her ABSG role is provided by the Gambling Commission. In previous employment, HW worked on contracts funded by GambleAware in a previous role and currently on a project looking at gambling and suicide. GambleAware are a national charity designated by government to fund research into gambling. Funds are provided by industry but decisions about what research is commissioned and the research questions are made by the Gambling Commission, advised by ABSG. GR is employed by the University of Glasgow. She has received research funds from the Economic and Social Research Council, the Medical Research Council, the Danish Research Council, the Scottish government, and. the Responsibility in Gambling Trust (RiGT). Funding from RiGT was match-funded and administered by the ESRC. She was previously a member of RGSB. She has received honorarium from the Gambling Research Exchange Ontario, Alberta Gambling Research Institute (AGRI) and the Gambling Commission. RDR is employed as a member of faculty by Bangor University. Previously, he has received funding from RiGT and GambleAware to support two unrelated projects. He has served on the research panel that previously advised the RGSB. He holds an unrelated consultancy agreement with Pfizer. EL has received research funds from the Victorian Responsible Gambling Foundation, Gambling Research Australia, Department of Human Services, New Zealand Ministry of Health, Education Queensland, Lowitja Institute, Australia’s National Research Organisation for Women's Safety, and the National Health and Medical Research Council. She has received an honoraria from Gambling Research Exchange Ontario and had travel expenses paid by Victorian Responsible Gambling Foundation, Gambling Impact Society, Gamble Aware, and the Gambling Research Exchange. None of these bodies had a role in manuscript design, data interpretation, or writing of the manuscript.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

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Public health has a tradition of addressing emerging and complex health matters that affect the whole population as well as specific groups. AIDS, environmental tobacco smoke and violence are examples of contemporary health concerns that have benefited from public health analysis and involvement. This article encourages the adoption of a public health perspective on gambling issues.

Gambling has been studied from a number of perspectives, including economic, moral, addiction and mental health. The value of a public health viewpoint is that it examines the broad impact of gambling rather than focusing solely on problem and pathological gambling behavior in individuals. It takes into consideration the wider health, social and economic costs and benefits; it gives priority to the needs of vulnerable and disadvantaged people; and it emphasizes prevention and harm reduction.

This paper looks at the public health foundations of epidemiology, disease control and healthy public policy, and applies them to gambling. Major public health issues are analyzed within a North American context, including problem gambling trends amongst the general adult population and youth, and their impact on other specific populations. There is significant opportunity for public health to contribute its skills, methodologies and experience to the range of gambling issues. By understanding gambling and its potential impacts on the public's health, policy makers, health practitioners and community leaders can minimize gambling's negative impacts and optimize its benefits.

Public health initiatives achieved remarkable successes in the last century, reducing morbidity and mortality from childhood infectious diseases such as diphtheria and measles; identifying modifiable risks associated with heart disease and cancer; and promoting healthy lifestyles and environments. At the beginning of this new millennium, public health has the opportunity to contribute understanding and solutions to a range of complex health and social issues that affect the quality of life of individuals, families and communities. The unprecedented expansion of legalized gambling is one such challenge that can benefit from a public health perspective.

In North America during the early part of the 20th century, most types of gambling were considered criminal, and legal gambling was highly restricted. Recently, an unprecedented expansion of legalized gambling has occurred within a new, expanded public policy framework. The primary driving force behind the explosion of gambling in North America is the economic necessity of states, provinces and local governments. Organizations in the United States promote the leisure and recreational aspects of gambling, whereas in Canada, the social benefits to charities, non-profit and community service agencies are emphasized (Campbell & Smith, 1998).

Historically, gambling has been understood from moral, mathematical, economic, social, psychological, cultural, and more recently, biological perspectives. Within the health care field, interest has come primarily from mental health and addiction professionals. Until recently gambling was not viewed as a public health matter. (Wynne, 1996; Productivity Commission, 1999; Korn, 2000). The value of a public health perspective is that it applies different lenses for understanding gambling behaviour, analysing its benefits and costs as well as identifying multilevel strategies for action and points of intervention. note 1 Policy makers, researchers and practitioners in the gambling field can incorporate a public health framework to minimise harmful consequences, enhance quality of life and protect vulnerable people.

A public health approach incorporates various elements that make it an attractive frame for addressing gambling issues. It offers a broad viewpoint on gambling in society —; not focusing solely on individual problem and pathological gambling. It conceptualizes a range of gambling behaviours and problems at points along a health-related continuum, which is similar to the approach taken in alcohol studies.

Public health goes beyond biomedical and narrow clinical models to address all levels of preventionnote 2 as well as treatment and recovery issues. It offers an integrated approach that emphasizes multiple strategies for action and points of intervention within the health system and community. A public health approach emphasizes harm reductionnote 3 strategies to address gambling-related problems and decrease the adverse consequences of gambling behaviour. It addresses not only the risk of problems for the gambler but also the quality of lifenote 4 of families and communities affected by gambling.

Public health action reflects values of social justice and equity, and attention to vulnerable and disadvantaged people. Public health professionals often play an advocacy role or act as a bridge between local citizens and policy makers on particular issues such as environmental tobacco smoke. One example where they play a similar role is the issue of government gambling policy acting like a regressive tax on lower income socio-economic groups.

Public health agencies exist at municipal, regional, provincial or state and federal levels. They are well suited to developing surveillance systems to track trends in problem and pathological gambling as well as the indicators to monitor social and economic impacts of gambling on communities and population groups. A public health position recognizes both costs and benefits associated with gambling. By appreciating the health, social and economic dimensions of gambling, public health professionals can foster strategies that minimize the negative effects of gambling while recognizing its potential benefits.

Public Health embraces the World Health Organization (WHO) characterization of health as the extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs and, on the other hand, to change and cope with their environment (World Health Organization, 1984). Health is viewed as a dynamic process and as a resource for living rather than an end in itself. It is a positive concept emphasizing social and personal resources as well as physical capacities. Building on this broad definition, gambling can be conceptualized as either healthy or unhealthy.

Nys Problem Gambling

Healthy gambling entails informed choice, including an awareness of the probability of winning, a low-risk pleasurable experience (i.e. legal, safe, regulated) and wagering sensible amounts. Healthy gambling sustains or enhances a gambler's state of well-being. Conversely, unhealthy gambling refers to various levels of gambling problems. This terminology complements the notions of healthy people, families and communities.

During roughly the same period that gambling was beginning to be seen as health issue in the 1980s and 1990s, there was a growing interest in healthy public policy. This expression was embedded in the WHO Ottawa Charter for Health Promotion in 1986, followed by the Adelaide Statement on Healthy Public Policy in 1988 (World Health Organization, 1986; World Health Organization, 1988). Healthy public policy refers to the WHO's thrust that policy initiatives in every sector should promote health-sustaining conditions.

In Canada, gambling is regulated under federal law, the Criminal Code of Canada, adopted in 1892. Only governments can “manage and conduct” gaming ventures or authorize charitable gaming under license. Private sector ownership is prohibited. Over the years, periodic amendments to the sections on gambling have permitted its growth, but only since the 1970s have lotteries and casinos been operating legally. In 1985, computer, video and slot devices were legalized and the provinces were given exclusive control of gambling. Stakeholder and social policy groups have raised concerns about the role of government policy in encouraging gambling, while at the same time, protecting the public interest.

Public health is the study of the distribution and determinants of health, disease and mortality in a defined population and the of related public policy measures to prevent, eliminate or control its occurrence and spread. Epidemiology is its central empirical research tool. Prevalence estimates of gambling-related problems in the general adult population have been carried out in numerous North America jurisdictions. Fewer epidemiological reports have described the impact of gambling on vulnerable and specific populations such as youth, women, older adults and Aboriginal people. To date, no Canadian national prevalence study of problem and pathological gambling has been commissioned. There remains a need for research on the incidence of pathological gambling and longitudinal studies on its natural history in gamblers.

A review of existing prevalence studies by the Harvard Medical School Division on Addictions revealed that 152 gambling prevalence studies have been conducted in North America as of 1997, including 35 in Canada (Shaffer, Hall et al., 1999). The estimated lifetime prevalence in the general adult population for problem and pathological gambling combined (levels 2 and 3 in Harvard study nomenclature) was reported at 5.5%. There were no significant differences in prevalence rates between the United States and Canada. Male sex, youth and concurrent substance abuse or mental illness placed people at greater risk of a gambling-related problem. Studies carried out by the United States National Research Council and the National Opinion Research Center at the University of Chicago as part of the National Gambling Impact Study Commission generally support these prevalence estimates (National Gambling Impact Study Commission, 1999; National Research Council, 1999).

The communicable disease control paradigm of public health is instructive to the gambling phenomenon. It describes the causal factors and interactions of host, agent and environment that contribute to a particular infectious disease, such as AIDS, and the strategies necessary to control its spread (see Figure 1). This model resembles the addictions paradigm of drug, set and setting that illustrates the interactions amongst these components which lead to a particular drug use experience and a range of possible outcomes (Zinberg, 1984).

Problem Gambling Worksheets

As applied to gambling (see Figure 2), the model can describe the multiple determinants of gambling problems and their complex interrelationships (Korn & Shaffer, 1999). The host is the individual who chooses to gamble, and who may be at risk for developing problems depending on their neurobiology, genetics, mental health and behaviour patterns. The agent represents the specific gambling activities in which players engage (e.g., lotteries, slot machines, casino table games, bingo, horse race betting). The vector can be thought of as money, credit or something else of value. The environment is not only the gambling venue but also the family, socio-economic, cultural and political context within which gambling occurs (e.g., whether it is legal, its availability and whether it is socially sanctioned or promoted). This public health paradigm invites a broad range of prevention and treatment interventions directed at various elements in the model.

A public health issue goes beyond consideration of the individual and their personal health to matters that affect groups of people who share common characteristics, geography or interests. The recent, dramatic growth of legalized gambling and its widespread acceptance raises concerns about its impact on the public's health and well-being. There are a range of public health issues related to populations at risk for gambling problems, suffering from gambling disorders or affected by the gambling practices of others. In addition, public policy decisions on gambling have implications for communities.

In the last decade before the millennium, an unprecedented expansion of government-sanctioned gambling occurred throughout North America. The dominant concern is the emergence of gambling addiction, which may be stimulated by increased availability and promotion of casinos, lotteries and VLTs. Currently, the estimated lifetime prevalence rates for problem and pathological gambling combined in the general adult population in both the United States and Canada is low; however, the Harvard meta-analysis of available studies shows that over the past 25 years there has been a rising trend.

The relationship between access to gambling and gambling problems is widely debated. A significant number of replication studies associated with the introduction of new gambling opportunities in states such as New York, Iowa, Minnesota and Texas demonstrate an increase in problem and pathological gambling (Volberg, 1995; Miller & Westermeyer, 1996; Volberg, 1996; Wallisch, 1996). Research done in the United States shows a higher prevalence rate in states with higher per-capita lottery sales and in areas within 50 miles (80 km) of casinos (Volberg, 1994; Gerstein, Murphy et al., 1999). These findings support the general conclusion that gambling expansion is associated with related to increases in problem and pathological gambling.

Youth is a development stage associated with experimentation, novelty and sensation seeking. However, the current youth generation is the first to grow up within a society where gambling is widely available and government sanctioned. The implication of this societal change for youth gambling behaviour and risk of developing gambling problems as adults is unclear.

Surveys in Massachusetts, Minnesota, Nova Scotia and elsewhere point to a high prevalence of problem and pathological gambling among youth, estimated to be two to three times higher than in the general adult population (Winters, Stinchfield et al., 1993; Shaffer, LaBrie et al., 1994; Poulin, 2000). A meta-analysis showed that the estimated lifetime prevalence for both problem and pathological gambling in the adolescent study population was 13.3% (14.0% for the college population), a proportion that has been relatively steady over the past 25 years (Shaffer, Hall et al., 1997). This high prevalence of gambling and gambling-related problems among youth, including sports betting at colleges and universities, is cause for concern and invites innovative approaches to prevention.

A number of special populations have been identified for focused attention because of their financial vulnerability, health status or distinct needs. This review of special populations examines people from lower income socio-economic groups, women, Aboriginal people and older adults, but it is not inclusive. Other groups that deserve consideration include ethnocultural minorities, incarcerated populations, substance abuse and mental health treatment groups and gambling industry employees. In general, gambling research within special populations is in an early phase, and these groups deserve further systematic study before conclusive statements can be made.

There has been considerable interest in the relation between gambling and socio-economic status. Recent Statistics Canada reports indicate that although gambling participation rates and actual expenditures tend to increase with household income, lower income households spend proportionately more than do higher income households (Marshall, 1998; Marshall, 2000). For example, in households in which at least one person was involved in gambling, those with incomes of less than $20,000 spent an annual average of $296 on gambling pursuits. This sum represented 2.2% of total household income, whereas those with an income of $80,000 or more spent $536, only 0.5% of total income. Given the share of gambling revenue in Canada and elsewhere that goes to government, these data suggest that gambling expenditures may be regarded as a voluntary but regressive tax that has a proportionately greater impact on lower income groups.

Women appear to have distinct gambling behaviours; and they are gambling more now than in previous years. In the United States, the percentage of women who have ever gambled rose between 1975 and 1998 from 22% to 82%. In the same period, the percentage for males increased from 13% to 86% (Gerstein, Murphy et al., 1999). Female gamblers prefer slot machines, VLTs and bingo to action table games and horse racing. Compared to males, females gamble more to escape, reduce boredom or relieve loneliness than for excitement, pleasure or financial gain (Coman, Burrows et al., 1997).

Aboriginal Peoples deserve attention because of the evolution of gaming policy and its potentially positive economic impact on Aboriginal communities through revenue generation and employment. At the same time, Aboriginal Peoples may be particularly vulnerable to the negative impacts of gambling for a variety of complex health and social reasons.

There has been considerable interest but little empirical research into the gambling behaviour of seniors who are a sizable and growing proportion of the adult population (North American Training Institute, 1997; Gerstein, Murphy et al., 1999; McNeilly & Burke, 2000). Seniors appear to be disproportionately represented at bingo halls, charitable gaming activities and day excursions to casinos. Although seniors are generally considered low risk-takers, there are concerns about their vulnerability to gambling problems springing from fixed incomes, social isolation and declining health. However, seniors may also receive health benefits from gambling activity and its impact on social connectedness. Research that examines the impact of gambling on depression, physical mobility and quality of life would enhance our understanding of the risks and benefits of gambling for seniors.

Gambling-related family problems deserve to be positioned centrally as important public health issues. A healthy family is integral to developing and sustaining individual self-worth, meaningful interpersonal relationships, mutual respect and personal resiliency. Robert Glossop of The Vanier Institute of the Family recently noted, “Families are perhaps the central determinant of health, the central influence in the lives of individuals that determine their health status and their chances of survival” (Avard, 1999). When family members are problem or pathological gamblers, they can adversely affect their relatives and significant others. To date, researchers in the gambling field have described a range of negative health and social consequences for family members associated with adult disordered gamblers. These effects have been identified in spouses (Lorenz & Yaffee, 1988), siblings (Lorenz, 1987), children (Jacobs, Marston et al., 1989) and parents (Heineman, 1989; Moody, 1989). Family issues include dysfunctional relationships, loss of family income, neglect, violence and abuse. Both the general public and health professionals need to be better informed of these potential consequences and elaborate a full range of family support interventions.

When jurisdictions face the opportunity to establish a gambling facility or expand gambling activities, there is often extensive, heated community debate regarding the social costs and economic benefits. Ideally, a community gambling assessment is shaped by consideration of local community needs, community values, strategic plans and research findings on community impact. Active participation of its citizens, involvement of key stakeholder groups and transparent decision-making are characteristics of a successful community process.

The outcome of this process should preserve or enhance the quality of community life; sustain or improve the overall health status of its members; and demonstrate local economic vitality as a result of either the presence or absence of gambling. Ongoing monitoring and impact analysis is necessary to evaluate the decision over time and to make appropriate adjustments.

Health Promotion Gambling Problems Since

The Internet provides a new and virtual environment for gambling. It has experienced explosive growth in the numbers of gambling Web sites, players and revenues (Adiga, 2000). It is unregulated in North America; operating offshore, it offers sports betting and casino-style gambling opportunities to individuals possessing a computer modem and a credit card. It attracts gamblers because it provides access to gambling activities at anytime in the privacy of their home or office. Underage gambling is difficult to monitor.

Technology has become a significant dimension of gambling in general. Concerns have been expressed about the wide availability and addictive potential of VLTs. On the positive side, computer- and Web-based technologies can incorporate personal risk assessment tools for gambling problems, and innovative prevention programs and monitoring instruments. One type of gambling that has received little attention to date is gambling that occurs in the financial world. Economic well-being is a significant determinant of population health. Thus, high risk or impulsive financial speculation, such as day trading, can have profound impacts on health status and social institutions.

What is done to resolve a particular societal matter depends on how it is framed. Approaching gambling from a public health perspective offers a strategic vantage point to address its broad health challenges and inform related public policy.

Three primary principles guide and inform decision-making. The first is to ensure that preventing gambling-related problems is a community priority, along with the appropriate allocation of resources to primary, secondary and tertiary prevention initiatives. The second is to incorporate a mental health promotion approach to gambling; one that builds community capacity, incorporates a holistic view of mental health (including its emotional and spiritual dimensions) and addresses the needs and aspirations of gamblers, individuals at risk of gambling problems and those affected by them. The third principle is to foster personal and social responsibility for gambling policies and practices.

These principles in turn inform a set of public health goals:

• to prevent gambling-related problems in individuals and groups at risk of gambling addiction
• to promote informed and balanced attitudes, behaviours and policies towards gambling and gamblers both by individuals and by communities
• to protect vulnerable groups from gambling-related harm.

An action agenda based on these public health goals and principles has been proposed. note 5

In conclusion, this public health perspective on gambling issues offers policy makers, researchers, health practitioners and community leaders a focus for public accountability and the opportunity to minimize gambling's negative impacts while balancing its potential benefits.