Professor Maggie Rae, President, Faculty of Public Health and Greg Fell, Vice President, Association of Directors of Public Health have written to the Rt Hon Chris Philp MP, Parliamentary Under Secretary of State (Minister for Tech and the Digital Economy) ahead of the publication of the Gambling Act review with the following recommendations for protecting the public from being harmed or exploited by gambling and the gambling industry.
All members of society have the right to live without unnecessary and preventable risk to health and safety from gambling products and gambling industry practices, whether land-based or online. Society should not be subjected to the marketing strategies of the gambling industry. Any person who gambles should be safe from preventable harm regardless of their ability to protect themselves.
The ways in which the design, marketing and accessibility of gambling products have advanced in recent decades cannot be overstated. These developments have transformed gambling into a commercialised industry based on rapid and intense consumption.1 The UK has experienced the impacts of these changes first-hand: its gambling industry is now a highly profitable and powerful trans-national industry with access to sophisticated technologies to optimise its marketing practices and the profitability of its products with profound implications for people lives, their health, and public policymaking. Notably, children and young people are now being exposed to gambling marketing and products on an unprecedented scale,2-4 creating the next generation of consumers.
The gambling industry has a primary objective to maximise its profits. Gambling industry actors, as with any private sector actor, have an obligation to act in the interests of the company and its shareholders, not the consumer. Their primary purpose therefore is to ensure that company profits are maintained or ever-growing, and the only source of that income is customer loss. Further, those harmed by gambling pay a disproportionate share of that profit, and they are more often in our most deprived and marginalised communities.5 Therefore, the profits of the industry are built on further impoverishment of already struggling communities and this creates an insurmountable conflict of interest with any efforts to reduce harms and inequity.6,7
While there may be instances when some people enjoy engaging with certain gambling products, the risk of harm is very poorly communicated to the public, and many people experience a wide range of harms, including those who are harmed by others’ engagement with gambling. Some of these harms – with mental health, financial and social consequences5,8,9 – are poorly documented and quantified, but they are experienced by the public nonetheless. From a public health perspective, there is an inherent conflict of interest that exists within the business model of the gambling industry: the more money that is acquired from the public, the greater the industry’s profits which simultaneously increases the risk of harms to people who gamble, their families and communities. Furthermore, funds that are raised from gambling activities represent an unstable form of funding that is often derived from those who can least afford it or are experiencing harm, which directly conflicts with government commitments to the strengthening of the UK’s resilience post COVID-19 and to “levelling up”.
It is in the gambling industry’s interest to downplay the risks and the scale of the harm caused by their products and practices, and it benefits from a lack of robust, independent research on the impacts of the industry and gambling policies. This practice and other strategies adopted by the gambling industry are well documented in other industries, such as tobacco, fossil fuel, alcohol, lead, and pharmaceuticals, and have been employed to protect corporate interests at the expense of public health for decades.10,11
Sustainable funding of public health approach to gambling
Sustainable funding of public health measures to address gambling harms is obviously critical. The current situation where gambling research, education and treatment are mainly funded by voluntary contributions from the industry or fines issued by the regulator, is deeply problematic and incommensurate to the burden of harms. It should go without saying that implementation of any funding mechanism should be directly linked in a ring-fenced way to regulatory interventions to reduce harm. If there isn’t a fall in profits then it might be assumed we aren’t reducing harm.
Any model of sustainable funding needs to pass a number of criteria:
- Firstly, there needs to be enough funding to address the level and breadth of harm to society from the practices of the industry and the nature of the products. There will need to be transparent commitment to an agreed proportion of funding to be directly allocated to gambling harm prevention and reduction.
- Secondly, there needs to be absolute transparency on how the funding is administered, the governance framework and absolutely no direct or indirect industry influence there is in this area. There should be a much stronger role for DHSC in the administration.
- Thirdly, there should be a clear and published aim for the levy, supported by evidence, for adopting a given form of levy or tax; that is, to change behaviour of individuals, and/or the industry, or simply to fund public health-related activities. There should be establishment of robust mechanisms to mitigate potential negative consequences of any new funding system.
- Fourthly, whilst the current public narrative surrounding funding focused on treatment and research is welcome and necessary, those activities themselves will have limited impact on population level harm, regulatory measures are still required, and prevention activities at local, regional, and national level also require funding and relevant policy levers to be effective.
- Finally, there should be a clear and transparent process for ongoing monitoring and review of the levy itself and the activities funded by it. There should be regular checkpoints to assess this.
It should be recognised that acceptance of gambling proceeds also leads to a situation where government and other organisations become dependent on the gambling industry, creating conflicts of interest that undermine policymaking and taking action to prevent harms as such action threatens this funding stream.12,13 These dependencies and conflicts of interest represent often unseen major public health challenges. Considerations such as these are important when weighing up the merits and demerits of any sustainable model of funding for public health prevention based directly on an industry levy. Overall the evidence on the relationship between consumer behaviour and the price of gambling is inconclusive, and a levy is likely be priced into the product or level of pay-outs (to protect profit) and this cost passed onto consumers. The gambler may thus pay the price of the levy but without any concomitant reduction in use. However, taxes or fees, when high and consistently applied, are likely to impact the behaviour of gambling operators.7 The potential for a given levy or a tax to be regressive given the nature of gambling activities, must be taken into consideration, particularly during a cost-of-living crisis. There is a significant moral jeopardy inherent to the use of gambling proceeds which warrants detailed consideration.14 Evidently these caveats and other considerations warrant public debate.
Marketing and promotion
Marketing and promotion strategies, including but not limited to sponsorship, need to be in scope of any review of the Gambling Act. The assertion that there is no ‘causal proof’ of a direct link between this activity and harm serves as a distraction and undermines productive debate, especially given evidence from other industries. This framing overlooks the complex interplay between different marketing exposures and normalisation processes that influence gambling activities, each of which likely has a contributing role in increasing the risk of harm. The industry directs increasingly large amounts of funding, in the order of hundreds of millions of pounds, on development of marketing strategies that utilise rapidly advancing technologies. It would not do so without evidence that marketing leads to higher consumption and a larger consumer base – similarly demonstrated by other industries. Given that we know higher consumption will equate to higher harm at both individual and population level it is therefore critical that government acts to regulate marketing and promotion in the interests of public health. Additionally, industry-funded and promoted research on the impacts of gambling marketing should be subject to independent peer-review and re-analysis prior to any inclusion for use in policymaking in this area given the conflicts of interests that are present.
Calls for a ‘public health approach’
Recent progress in our understanding of the scale and breadth of gambling harms in the UK has brought an important and critical shift in public and policy debates on gambling. This has been accompanied by calls for a ‘public health approach’ to gambling harms to be adopted, with the UK Government, among others, recognising the harms created by the current gambling system as a public health issue. Despite the harmful nature of gambling being recognised well before the development of the Gambling Act 2005, for too long the obligations of the government to protect and promote the health of the UK public have been delegated to the corporate social responsibility (CSR) activities of the gambling industry.10,15 Promoting and protecting the public’s health and other human rights are core functions and duties of government and its public bodies. Additionally, the current regulator is dependent on licensing fees obtained from the industry and recent reports by the Public Affairs Commitment and the National Audit Office reveal a concerning lack of capacity and data that are critical to acting to protect the public’s interests.16,17 While some policy changes that have been made in response to rising concerns about harms represent positive developments, it is concerning that many have either been initiated by the industry, done in collaboration with the industry and/or have been incremental and reactive. There has been minimal transparency regarding policy design, and no robust, independent system for the evaluation of impact has been established to date.
Public Health England’s review findings on the scale of the issue concluded that 0.5% of our population were gambling at a problem level, with 7% of the UK population negatively affected by gambling.5 This equates to over 4 million people in England and over 5 million people across the UK; 1 in 12 people are either directly or indirectly affected by gambling-related harms. The distribution of these negative impacts is unjust and unfair, with the greatest burden and risk of harmful gambling being experienced by socio-economically deprived, disadvantaged and minority groups. These harms can impact on health, both mental and physical, and the wider factors that are essential to health, including social relationships, finances, housing and energy security, employment, and education. These estimates likely downplay the scale of the problem given concerning inadequacies in the current system’s ability to identify and act upon gambling harms; problem gambling prevalence surveys alone are not sufficient for measuring all gambling harms, their lifetime prevalence, or trends over time.7 The scale of funding needs to be matched to scale of harm. Currently the total cost of the harms experienced, which fall disproportionately on marginalised and deprived groups, far outweighs what is recovered from industry, much of which is then directed towards poorly-evidenced measures favoured by the industry that do not threaten its interests. Gambling harms are thus an issue of inequity, injustice and unchecked corporate influence and power – a situation that is deeply concerning given the current UK context where multiple health and social crises are colliding to deepen poverty, ill-health, and misery.
A public health approach in response to gambling harms is clearly warranted. Unfortunately, this has not yet translated into a coherent public health strategy or effective action. Transformational changes in how we understand gambling and regulate the industry are needed if the public’s health is to be prioritised. Such change is possible and is supported by the public. Here we set out key policy objectives describing a) what we mean by a public health approach to gambling harm, and b) how this should be implemented.
A ‘public health approach’ to gambling harms
A public health approach is one that is guided by a vision that priorities the public’s health, and that is based on core values and principles, such as human rights, equity, and collective responsibility.10,11
Gambling harms already reflect social and health inequalities; with potential to affect anyone but with greater harm where there is increasing vulnerability in terms of mental health, income deprivation, age, gender, race, and ethnicity. Anyone may be vulnerable to gambling harms at some point in their lives. What we have a present is a gambling policy system and industry that creates, exacerbates, and exploits vulnerabilities, counter to the governments duty to protect the health and wellbeing of everyone. Risks, harm, and opportunities to intervene to reduce future harm occur before someone reaches the point of gambling at a problem level, and many individuals and families present at the point of crisis or not at all5, 18,19 ; an equitable and effective solution therefore cannot be focused around clinical or individual intervention but on the structural, contextual and commercial drivers of harm.
Action to prevent harm is required across the whole population, not just directed at those most at risk or most vulnerable. The picture of gambling harms is complex which means a comprehensive and evidence-based independent framework of policies is needed. Such an approach aims to prevent harm by addressing drivers of gambling, both online and land-based; for example, limiting availability (including location, opening hours, and age restrictions) and marketing (including advertising, sponsorship, product design, placement, price and other promotions); providing information that is understandable, effective and covers all forms of gambling; and providing treatment-based services that are evidence-based, and independent. This can support the breadth of harms that are experienced by engagement with all forms of gambling while avoiding stigmatising those who experience harm.
This view is supported by non-commercial and individual stakeholders5, 20 including those with lived experience of gambling. Such an approach requires cross-departmental working and would be informed by the evidence and experiences gained in addressing the harms associated with other harmful industries and products, that focus on de-normalising the industry and its products, and that limit advertising, accessibility, availability, and affordability.
- Adopt a public health framework to gambling that (i) recognises the harmful nature of the industry, and the threat posed by conflicts of interest to research, education, treatment and policymaking, and (ii) prioritises prevention of harm to those who gamble online and via land-based forms of gambling and harm to others. Examine other framework approaches with proven success e.g., tobacco – and adopt similar comprehensive approaches to improve public health impact of gambling policy.
- Develop and mandate an agreed approach to transparency, declaration of interests and identification of trusted partners in the space of gambling harm prevention, building an alliance (for example the Obesity Health Alliance) which can collaborate to further define and uphold the public health approach.
- Work via this alliance to build local, regional and national evidence of harms from gambling, with relation to other agendas including NHS and social care, incorporating broader measures of harm caused by gambling. Forge links with related government strategies such as tobacco control and alcohol and online harms, ensuring coherence. Test and strengthen this evidence base applying collectively to inform and prioritise policy recommendations and amplify where appropriate to the public, and build on existing public support for such measures
- Adopt robust and dynamic regulation of both industry and products: strengthen the independence of the regulator from industry influence and set the primary objective of the regulator and the local authority licensing teams as ‘aim to protect the public’ instead of ‘aim to permit gambling’. Commit to ensuring that the regulator holds sufficient evidence and capacity to monitor and act to prevent and reduce harm, working in partnership with local licensing authorities. Such actions would include the prevention of clustering of gambling outlets in vulnerable communities alongside consideration of clustering with other forms of outlets/services with potential negative health impacts, and the banning of high-risk gambling products. Building public health considerations into local regulatory processes – for example the licensing act, including considerations of cumulative impact – would also demonstrate clear commitment to reducing harm and acting in the interests of public health. Design of the regulatory structures should be informed by the evidence on what promotes or hinders acting in the public’s interest, drawing on the international literature on other regulatory agencies. To take a public health approach, it is vital that people with sufficient public health expertise and experience form part of that regulator at board level and within the staff team.
- Design and improve national policy based on successful practice in other countries on related public health issues, such as banning of advertising and mandating use of government-issued warnings. Recommend and support similar application to local policy approaches.
- Conduct independent and robust evaluation of gambling policies that are implemented including assessment of unintended consequences, using research to inform policy design, and modelling the potential impact of future policy changes, recognising the complexity added by the scale and diversity of gambling products and features and other factors that influence gambling activities.
Shifting understanding and framing gambling harms informed by public health evidence
Public understanding of the serious nature of gambling and gambling harms has been undermined by a narrative promoted by successive governments and the industry that gambling is enjoyable and safe if people do it in a responsible way and for the right reasons. As with smoking, the public is often led to believe that any addiction is down to personal choice, some individual fault or lack of control.15,21 This way of thinking about gambling harms aligns with the business interests of the gambling industry, with very little concern for life or health. This framing is stigmatising of those who are harmed,22,23 and shifts the blame on to individuals including children and young people.24 The resulting shame discourages help-seeking, limiting the reach and effectiveness of support and treatment. The gambling industry uses substantial resources and expertise to shape norms and environments, with sophisticated design and marketing of products facilitating 24/7 access to gambling – and inevitably addiction. Gambling can harm, and it should not be seen as exceptional to other harmful industries – all of which can be labelled as fun or beneficial if a limited way of understanding the issues is given preference over a more comprehensive and equity-focused perspective.
The UK public have the right to be provided with legitimate and independent sources of health advice about gambling, the risks involved and the importance of addressing conflicts of interest. The gambling industry and those in receipt of its funding hold conflicts of interest that risk undermining the prioritisation of preventing harms, as a substantial proportion of gambling industry earnings are derived from the those experiencing harm or whose gambling may be causing harms to others. The gambling industry has not prioritised the prevention of harm to date, regulatory fines or settlements have not deterred harmful corporate behaviours, and the industry does not possess competence in public health.
To prevent harm, new ways of understanding and regulating gambling are needed. This should include reframing gambling harm as a population issue and oriented around the very nature of products and industry practice, avoiding individual labels and narratives which imply blame, lack of willpower or inherent weaknesses, and acting to decrease stigma. We should also be openly and repeatedly challenging use of stigmatising language and narratives promoted by industry actors and others. We should expose tactics that have been adopted by industry to draw people into gambling so the public are informed of these practices and the impact they have on behaviours.25-28
- Adopt a narrative that reflects the risk of harm from gambling and communicates the potential for gambling harms to affect anyone. Provide independent and effective public health messaging that informs the public of the harms and risks associated with gambling and the industry’s practices, explaining gaps in current knowledge and why they exist. Public health information must reflect advances in the industry and remain relevant as products and marketing strategies change and become more sophisticated.
- Commercial actors do not have a role in providing public health advice and youth education. OHID should take a lead role in providing public health advice, warnings and education in relation to gambling, supported by relevant clinical and academic organisations who are free of conflicts of interest. Industry should be mandated to present such government-issued warnings and information, guided by approaches known to be effective in other harmful product industries.
- Regulate advertising and sponsorship of gambling in the interest of public health. This could involve placing the burden of proof on industry to establish that its products and the way in which it wishes to market them are safe, prior to formal approval by the reformed regulator whose primary mandate is to protect the public (as outlined above).
Protecting policymaking, regulation, research, education and treatment from industry influence
Policymaking in areas that affect health should be protected from undue influence by the gambling industry that undermines adopting a public health perspective and understanding of the nature and scale of the harms associated with its products and practices. Misuse and misrepresentation of evidence and distortion of the scientific process to promote corporate interests allows harmful industries to influence the policy-making process and approach to regulation. Any engagement with the industry in this context should only be justifiable if doing so is deemed essential to promoting the public’s interest, for example, to facilitate implementation of independently developed public health policy. It should be the exception rather than the rule; industry has shown it does not act in a socially responsible way or respect high standards of evidence use.
Being evidence-led involves having (1) a vision and set of values and principles that the evidence can support in realising, and (2) a joined-up approach to gather this evidence. Use of evidence in policymaking involves recognising the value provided by different forms of evidence as well as drawing on the best available evidence at hand to protect life, promote health and prevent harm and inequities. We need to show how gambling harm is affecting our population individually, collectively, economically, socially, and how this also influences and interplays with other health concerns such as mental health and violence. There is value for programmes beyond gambling to benefit from action on this agenda. Measurement of harms to society should not be solely based on problem gambling assessment but upon a range of factors which are impacted and influenced by gambling.
Current funding and delivery systems of gambling research, treatment and education are lacking in governance and are compromised by conflicts of interest. Evidence shows that systems that come to depend on industry income as a source of funding or that include harmful industries as a partner in addressing the health harms caused by their products tend to adopt policies that align with corporate interests at the expense of evidence-based interventions that protect public health but impact on industry profits; this influence is a public health issue.
- Have the promotion of the public’s health as the primary focus of gambling policy, including the protection of children and young people and their rights to live and grow in safe and healthy environments.
- Adopt clear principles for engagement with industry actors informed by established guidelines. Develop and agree stringent processes to review any engagement activities including existing arrangements, with accountability and openness with the public.
- Protect gambling policies from influence from the gambling industry and others with conflicts of interest, and limit industry input to its areas of competence and when required to implement previously established public health policies.
- Strengthen policy governance including addressing untransparent lobbying, conflicts of interest, political donations and hospitality from the industry, and ‘revolving-doors’ between government, civil service, and the gambling industry that undermine public health policymaking.
- Establish stable and independent funding streams to prevent and reduce gambling harms which are free of industry influence and do not create dependencies on industry earnings. Raise the profile and implement workforce guidance to actively avoid conflicted funding sources.
In summary, gambling has become increasingly easy to access, glamorised, and promoted to a wide audience which includes children. This has normalised gambling creating a cycle in which people engage with harmful and sophisticated products that are portrayed as fun leisure pursuits with only industry-favoured poorly or unevidenced measures in place as forms of protection; and once harmed people and families are failed in the way they are understood and supported, exacerbating those harms. People are therefore exposed and encourage to use harmful products with few independent and evidence-based policies in place to inform and protect them from gambling harms.
To address gambling harms in the UK, a true public health approach should: prioritise safety; engage with the evidence on the commercial determinants of health and the impacts of conflicts of interest; and protect regulation, science and policymaking from harmful corporate influence. Protecting and promoting health and equity must inform the design of effective regulatory structures with serious consideration given to which government departments are best placed to oversee which aspects of gambling regulation. There is much that can be learned from other countries and public health issues to avoid delays and strengthen policy design, and regulation must be dynamic and stay ahead of developments in the industry. It is obviously vital that a public health approach to gambling is not in name only. Until the recommendations set out here are addressed fully there is a clear danger of tokenism about the moniker of “a public health approach”.
- Adams PJ, Raeburn J, de Silva K. A question of balance: prioritizing public health responses to harm from gambling. Addiction 2009; 104(5): 688-91.
- Clark H, Coll-Seck AM, Banerjee A, et al. A future for the world’s children? A WHO-UNICEF-Lancet Commission. The Lancet 2020; 395(10224): 605-58.
- Pitt H, Thomas SL, Bestman A, Stoneham M, Daube M. “It’s just everywhere!” Children and parents discuss the marketing of sports wagering in Australia. Aust N Z J Public Health 2016; 40(5): 480-6.
- Pitt H, Thomas SL, Randle M, et al. Young people in Australia discuss strategies for preventing the normalisation of gambling and reducing gambling harm. BMC Public Health 2022; 22(1): 956.
- Public Health England. Gambling related harms evidence review 2021.
- Adams PJ, Livingstone C. Addiction surplus: the add-on margin that makes addictive consumptions difficult to contain. Int J Drug Policy 2015; 26(1): 107-11.
- Sulkunen P, Babor TF, Egerer M, et al. Setting Limits: Gambling, Science and Public Policy: Oxford University Press; 2019.
- Farrell L, Fry JM. Australia’s gambling epidemic and energy poverty. Energy Economics 2021; 97: 105218.
- Markham F, Doran B, Young M. The relationship between electronic gaming machine accessibility and police-recorded domestic violence: A spatio-temporal analysis of 654 postcodes in Victoria, Australia, 2005-2014. Soc Sci Med 2016; 162: 106-14.
- van Schalkwyk MCI, Blythe J, McKee M, Petticrew M. Gambling Act review. BMJ 2022; 376: o248.
- van Schalkwyk MCI, Petticrew M, Cassidy R, et al. A public health approach to gambling regulation: countering powerful influences. The Lancet Public Health 2021.
- Adams PJ. Gambling, freedom and democracy. Abingdon, UK: Routledge; 2008.
- Adams PJ. Gambling and Democracy. In: Bowden-Jones H, Dickson C, Dunand C, Simon O, eds. Harm Reduction for Gambling A Public Health Approach. London: Routledge; 2019.
- Adams PJ. Moral Jeopardy: Risks of Accepting Money from the Alcohol, Tobacco and Gambling Industries: Cambridge University Press; 2016.
- van Schalkwyk MCI, Maani N, McKee M, Thomas S, Knai C, Petticrew M. “When the Fun Stops, Stop”: An analysis of the provenance, framing