APG on Reducing Harm Related to Gambling: Public health approaches to gambling-related harms in NI

02 February 2023 14:37
  • Consultation Responses

    APG on Reducing Harm Related to Gambling: Public health approaches to gambling-related harms in NI     

    January 2023

    Advice NI response                                                               

    What public health policies and interventions have the most potential to effectively prevent and reduce gambling-related harms?

    From ‘Interventions to reduce the public health burden of gambling-related harms: a mapping review’[1]:

    “A public health approach suggests that there are opportunities to reduce gambling-related harms by intervening across the whole gambling pathway, from regulation of access to gambling to screening for individuals at risk and services for individuals with an identified gambling problem. The dearth of evidence for some interventions means that implementation must be accompanied by robust evaluation.”[2]

    To paraphrase, this approach suggests prevention; supervision and intervention, across the gambling pathway. A BMJ[3] article echoes this suggestion: “Public health approaches to reduce harms related to gambling should encompass a range of population based approaches supported by regulation, legislation and funding”[4]

    While financial concerns may present as the most immediate issue, the problem gambler may experience other gambling related harms [as detailed later in this response], so debt is not an isolated issue for problem gamblers.  It could be suggested that a multi-strand approach with different agencies would have the most potential, and be best placed to address issues that arise from gambling: in November 2021, the APG report on the future of gambling regulation recommended that: The relevant Executive Departments (Communities, Health, Education and Justice) must work closely to both prevent and treat gambling related harm and end a disjointed Executive approach[5].

    This comprehensive approach already exists for products that have an associated addictive potential, such as alcohol or tobacco [e.g. age-regulated access, NHS smoking cessation clinics etc].

    What types of harms are associated with gambling, and how do these impact individuals, families and communities?

    To consider first what the term ‘gambling related harms’ means:

    The Royal Society for Public Health adapted Langham’s taxonomy of harms, which describes seven pillars of harms related to gambling.

    The strongest evidence we found was for health harms, financial harms, and relationship harms.

    Financial harms (such as gambling related debt) affected both the gambler and their family and friends. ..While the evidence showed that gambling was not a direct cause of crime, there was qualitative evidence showing that gambling related debt causes some gamblers to commit crimes. Several studies reported that gambling led to housing problems, including homelessness.

    ..Health harms, we found suicidal events (attempts, ideation, and death by suicide) to be at least twice as likely among adults with gambling problems…..

    Gambling directly causes relationship problems… [including] poorer family functioning, low social support, relationship strain and in some cases there was evidence of domestic abuse.

    There was some evidence from qualitative studies that particular populations, such as migrants and people with learning disabilities, are at more risk of harm. Gambling may be making existing inequalities in these populations worse.[6]

    Financial

    This impact may appear to be the most immediate. Just one example is Alan Lockhart, from Doncaster, who took his own life eight years ago after his gambling spiralled out of control…There is an NHS gambling clinic in London and a second one could be set to open in Leeds, according to a government report.[7]  Each year at least three quarters of callers to the National Gambling Helpline and those accessing GamCare’s[8] treatment services report financial difficulties and two thirds mention some level of gambling debt.[9]

    Relations

    Financial harms then can generate relationship problems that directly affect family members.  One Advice NI client owed family members for clearing £25,000 of gambling debts.  Someone struggling to control their gambling might look to borrow money they can’t afford to pay back, often at high interest rates, or gamble with money that was intended for household bills. They may even steal from family or friends or commit fraud to fund their gambling. 

    For the partner or family members who might be linked to the gambler financially, it is not just the resulting debts and financial fallout that has a negative impact.  Trust can quickly break down, which is often hard to repair.[10]

    Also, gamblers could get dragged into borrowing from illegal lenders, which could put them and their families at risk. Since 2019, the Consumer Council has been conducting detailed quantitative and qualitative research into the prevalence of illegal money lending in Northern Ireland.[11]

    Health: 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.[12]

    The Gambling related harms evidence review[13] [updated January 2023] found further harms:

    Mental and physical health harms

    A high quality quantitative study showed that people with gambling disorder have an increased risk of dying from any cause, in a given time period, relative to the general population.

    Criminal and anti-social behaviour harms

    Gambling-related financial difficulties were associated with crimes by adult gamblers. This included theft and selling drugs. This criminal activity affected close associates and wider society. For example, gamblers took out loans in other people’s names, stole from friends and family and committed fraud.

    Cultural harms

    Cultural harms refer to the tensions between gambling and cultural practices and beliefs, and normalisation (where an activity and the associated harms become thought of as normal). These studies showed that gambling- related harm is influenced by cultural norms, so some gamblers and their close associates experience additional harm like shame and isolation. Gambling is normalised in society so harms can be passed on to the next generation.

    Safeguarding in the Gambling space is crucial to protect the vulnerable [under 18s; those with mental health/addiction issues; the elderly etc.] In Ireland, the 2019 version of the Gaming and Lotteries Act was passed recently. These reforms aim to bring… changes to the Irish gambling ecosystem, including creating a uniform age limit of 18 for all gambling services.[14]

    How do the characteristics, availability and accessibility of gambling products affect public health, and what can be done to mitigate the associated risks?

    The characteristics, availability and accessibility of gambling products could affect public health, through the proliferation and style of advertising that encourages consumers to engage in gambling.

    NI does not have an independent gambling regulator [yet], unlike the rest of the UK.  In GB, The UK Gambling Commission is responsible for regulating arcades, betting, bingo, casinos… as well as remote gambling, which including internet sites and telephone betting. However, ‘[if in N.I.] you’ll need to rely on district councils and the Betting, Gaming, Lotteries & Amusements (NI) Order 1985 for regulation of bookmaking offices, racing tracks, and bingo.’[15] N.I. district councils could be asked exactly what policies/oversight they are utilising to monitor the availability and accessibility of gambling products in their area.

    In 2023, gambling is no longer an activity that could only be found in betting shops and at sporting events.  Now there is a myriad of types of gambling: from betting shops, large on-line companies providing sports betting, casino and slot games, to the National Lottery.

    In England, The National Lottery is the most common type of gambling across all age groups, except among younger people where scratch cards are more common.[16] National Lottery products and scratch cards can be widely found, in newsagents and supermarkets across N.I. It is therefore easily accessible to consumers of all ages.

    Harmful gambling has a different activity profile to general gambling: it includes low National Lottery participation and high participation in online gambling[17]. Online gambling often provides offers to entice new customers. Examples include:

    • William Hill New Customer offer: Get £60 from a minimum £10 bet[18]
    • Paddy Power New Customer offer: £40 IN FREE BETS when you place a £10 bet on sportsbook PLUS 10 FREE SPINS for the daily jackpot games[19]
    • 888 Casino New Customer offer: 88 FREE SPINS, NO DEPOSIT + 100% up to £200 BONUS +25 FREE SPINS[20]

    Large advertising budgets, sophisticated website design and messaging, plus the increase of on-line sites [which could be specifically designed to appeal to a younger demographic] all facilitate ease of access to entice the customer.  As online betting is under the purview of UKGC, there may be little that can be done to protect N.I. gamblers through the current N.I. system.

    How does the advertising and promotion of gambling products affect public health, and what can be done to improve things?

    Gambling product advertising can be seen everywhere in Northern Ireland: from billboards and in print newspapers, to radio, television and online. Gambling logos can appear more than 700 times in a single televised football game… because logos on shirts do not count as advertising.[21]

    In GB, since gambling advertising and gambling itself were liberalised by the Gambling Act 2005, the promotion of gambling products has grown exponentially, with an annual spend now in excess of £1.5 billion and a growing amount of that happening online. It is worth noting that one in six adults follows gambling companies on social media, as do a surprising number of children[22]. Speaking in 2022, Lord Foster further states:

    ‘Also growing has been the level of public concern about gambling companies using ever more sophisticated means to attract new customers and persuade existing ones to spend more, using a range of techniques to keep customers hooked, from disguising losses as wins and celebrating near-misses, to offering so-called free money and free spins.’ [23]

    One of the challenges faced by DfC and other regulatory agencies, is that Gambling products are developed, marketed, and operated by a highly differentiated and profitable global industry.[24]  In order to challenge this, Northern Ireland lawmakers should be prepared to implement robust legislation, regarding issues including age-related access, advertising restrictions etc.

    The National Lottery has an extensive tv, radio and ad campaign, and much is made of the donations to charity it generates.  The National Lottery website is easy to navigate, and in bright colours, with cheerful stories about winners: note the website refers to its customers as ‘players’[25]: this deliberate use of language suggests that the customer is simply ‘playing’ a game, as oppose to participating in gambling. 

    In terms of helping customers who may have an issue, on the home page there is a simple box with the vague term ‘Dream Big. Play small’, and brief notes: ‘Set limits. Get reminders. Take time out. Using our tools can help you stay in control’; the customer then needs to click on the box for more information. Although this section deals with the serious issue of addiction, it employs notably subtle messaging, compared to the rest of the home page.

    User-friendly websites, that lure customers and minimises risk, could encourage more gambling participation.

    Baroness Chisolm noted ‘advertisers and platforms have access to sophisticated screening tools and accurately target children who are gambling. These ads should not be designed to appeal to children, with an emphasis on fun, cartoons, escapism and winning.’[26] – yet the emphasis of the National Lottery website appears to promote exactly this, only without cartoons.

    Safeguarding is crucial. Money and resources need to be specifically directed to attempt to tackle widespread gambling advertising and promotion.  In our response to the All Party Group, on Reducing Harm Related to Gambling, Advice NI stated:

    Advice NI strongly suggest due consideration be given to providing additional funding to consumer, advice and gambling support organisations that seek to prevent and address debt and addiction problems.  This could involve a well-funded, effective treatment programme including debt/ money management coaching and CBT therapies, potentially funded by a levy on the gambling industry.

    Advice NI supports the implementation of an Industry Levy, whereby gambling organisations help to fund addiction services/projects through DfC, the department responsible for gambling policy in N.I. 

    This could be implemented via tax returns, which are always submitted between Oct-Jan for the previous year: so for example, tax year 20-21 will be due by 31st Jan 22. The gambling organisations verify via submitted tax return, with fee issued and payable by April 22. 

    Millions of pounds are made/ annum by the gambling industry, through promoting and selling a product known to have negative impacts on public health, as researched by government agencies, charities and medical reviews. It is the moral responsibility of the industry to at least mitigate and/or address the negative impacts that their products have on Northern Ireland’s population. It is also incumbent for the government in Northern Ireland to use legislation and regulation to enforce this.

    How does gambling affect mental health?

    There is strong evidence demonstrating the relationship between gambling harms and suicidality, including among young people. Wardle and McManus (2020) demonstrate a significant and substantial relationship between suicide attempts and problem gambling even after factors like poor wellbeing, substance misuse and impulsivity have been taken into account.[27]

    The Mental Health Foundation states on its website: ‘Gambling can cause low self-esteem, stress, anxiety and depression if gambling becomes a problem. Gambling can become an addiction, just like drugs or alcohol, if you use it compulsively or feel out of control. Gambling can affect the part of our brain that releases dopamine’[28]

    Problem gamblers frequently have coexisting mental health problems and substance misuse. People with mental health problems have a higher than average risk of engaging in problem gambling while unwell. [29]

    Research by Money and Mental Health has shown that up to 93% of consumers with mental health problems find themselves spending more while unwell, and spending on gambling is frequently cited by consumers as a problem during episodes of poor mental health. Around a quarter of problem gamblers are receiving medication, counselling or therapy for a mental health or emotional problem - compared to 7% of those with no indicators of problem gambling. In designing policy protections, it is vital to consider the needs of problem gamblers in the context of their mental health.[30]

    How do we prevent children and young people from being exposed to gambling related harms?

    Young people and children can be affected by gambling in two ways. Young people may themselves develop an unhealthy relationship with gambling, which could have a detrimental and knock-on effect on their studies and overall development:

    ‘There is a clear link between problem gambling in adolescence and pathologic gambling in adulthood.’[31]

    Young people may also be affected by gambling related harm, due to a family member with a gambling addiction, which may present with other issues, such as debt, addiction and/or mental health concerns. 

    ‘If a child or young person has a close friend or carer who gambles, that individual is six times more likely to be a current gambler than those without a connection.’[32]

    In 2020, The Gambling Commission found that 58% of 11-16 year olds have seen or heard gambling adverts or sponsorship, of which 7% said this had prompted them to gamble when they weren’t already planning to.[33]

    A study published in December 2021 in the Journal of Gambling Studies shows that advertising is a predictor of at-risk and problem gambling in secondary school children. A recent Gambling Commission survey found that 34% of British bettors admitted to being influenced by advertising, noting that 16% claimed that ads caused them to increase their gambling.

    During the Lords debate on Gambling Advertising, Lady Chisolm stated:

    ‘The advertising code forbids the advertising of gambling to under-18s. Almost all forms of gambling are illegal for this age group, so they should not be a targeted audience, but gambling ads are not reaching children accidentally. Advertisers and platforms have access to sophisticated screening tools and accurately target children who are gambling….. E-sports gambling adverts appear to be more appealing to children and young people than adults—the figure is forecast to exceed $1 billion this year with an audience of 500 million, most of whom are children and young people.

    The Young Gamers and Gamblers Education Trust, which works with many schools and youth practitioners, has stated that all gambling advertising should be designed and displayed in a way that is appropriate for adults and avoids marketing techniques that appeal to children…We are now seeing a new and complex way of advertising contributing to the normalisation of gambling, as well as attracting young and vulnerable people to its audience.’[34]

    Some 13% said that ads led them to initially take up gambling, and nearly 15% said that viewing ads resulted in them taking up gambling again after taking a break. Earlier this year, researchers at Ipsos MORI and the University of Stirling found that 96% of young people aged 11 to 24 had seen gambling marketing messages in the last month and were more likely to bet as a result.[35]

    So gambling advertising needs to be regulated:  almost 60% of respondents to the APG on Reducing Harm Related to Gambling [Sep 2020] want to see a complete ban on all gambling advertising.[36]  More information and education is also needed, which would inform robust, holistic support for young people who participate in gambling, and for those whose family member with a gambling addiction.

    What are appropriate treatments for those with a gambling disorder?

    n/a

    Is the current system of support and treatment for those with a gambling disorder in Northern Ireland effective?

    n/a

    What is the relationship between gambling and social and health inequalities?

    Health inequalities are “unfair and avoidable differences in health across the population, and between different groups within society”. For example, when one individual or population experiences more consequences, or more severe consequences, from a disease than another despite equivalent exposure.[37]  Following a systematic review, the BMC[38] writes:

    ‘evidence suggests that gambling harms are disproportionately experienced by economically and socially disadvantaged groups. The National Strategy to Reduce Gambling Harm states “An effective prevention plan must seek to identify the right mix of interventions to be applied at both the population and individual level,” and so a thorough understanding of how an individual experiences harm would be beneficial in understanding gambling as a whole, and developing effective interventions.

    There are inequalities in the extent to which sub-groups of the population are affected by gambling. People at the greatest risk of harm are more likely to be unemployed and living in more deprived areas, have poor health, low life satisfaction and wellbeing, and have an indication of probable psychological health problems.’[39]

    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. At its most severe, gambling can contribute to loss of life.[40]

    Should the Department of Health be mandated to be responsible for the prevention and treatment of gambling-related harms?

    Arguably the DoH should not be the sole department responsible for prevention and treatment.  As quoted in the APG on Reducing Harm Related to Gambling - Inquiry Terms of Reference, in November 2021, the APG report on the future of gambling regulation recommended that:

    The relevant Executive Departments (Communities, Health, Education and Justice) must work closely to both prevent and treat gambling related harm and end a disjointed Executive approach[41]

    Should the Department for Communities be mandated to consult the Department of Health when developing gambling related policies and regulations?

    Yes, the public health ramifications of gambling are evidenced.  The DoH should have a vested interest in the gambling related policies DfC seek to put in place. While every suggestion from the DoH may not be implemented by DfC, surely insights from the DoH could be valuable for policy makers.

    The Institute of Public Health response to the APG on Reducing Harm Related to Gambling, suggested that legislation and a regulatory framework should be subject to a Health Impact Assessment, including a full impact assessment on health and social care services.[42]

    Advice NI recommends a whole system [cross-government] approach when developing gambling related policies.  A whole system approach involves applying systems thinking, methods and practice to better understand public health challenges and identify collective actions[43]. Organisations consulted could include: Health and Social Care; Local Government; Third Sector.

    What data should be collected to improve treatment services and harm-prevention measures?

    Ensuring all GDPR is adhered to, that depends on what information the agencies deem relevant to improve their services or ensure continued funding. Examples could be:

    • Number of service users and geographic location, so services can be targeted [e.g. towards specific areas of deprivation]
    • Age and sex of service users, to clarify demographics
    • Financial outcomes [money saved, debt addressed etc]
    • Non-financial outcomes [addiction counselling, improved familial relationships etc]

    Consultation responses from such stakeholders as Gamblers Anonymous and Addiction NI could provide more specific data suggestions, that echo the type of info they gather/hold.

    What effective policies used or proposed in other areas of public health could be translated to addressing gambling-related harms?

    n/a

    How should a new regulatory authority form work with health and social care services to address gambling-related harms?

    n/a

    What are your view on public health messaging and education in schools on the risks associated with gambling?

    n/a

    Contact Details, Advice NI Policy & Information Team

    Advice NI, Forestview, Purdy’s Lane Belfast BT8 7AR

    Tel: 0800 915 4604

    Kevin Higgins: kevin@adviceni.net

    Matt Cole: matt@adviceni.net

    Bridget Meehan: bridget@adviceni.net

    Charlotte Ahmed: charlotte@adviceni.net

     


    [1] National Library of Medicine [USA]

    [2]National Library of Medicine USA.

    [3] British Medical Journal, published by the British Medical Association

    [4] BMJ

    [5]APG Gambling & Public Health

    [6] RSPH.org.

    [7] BBC article

    [8] Gamcare: A GB charity that operates the Freephone National Gambling Helpline

    [9] Gamcare.org

    [10] Gamcare.org

    [11] Consumer Council Illegal Lending Research

    [12] BMJ

    [13] Gambling Related Harms evidence review

    [14] https://www.irishpost.com/entertainment/complete-guide-irish-gambling-laws-tourist-2020-178350

    [15] Casino.co.uk.

    [16] Gambling related harms review

    [17] Gambling related harms review

    [18] William Hill website

    [19] Paddy Power

    [20]888 Casino

    [21] House of Lords Debate

    [22] IBID

    [23] House of Lords Debate

    [24] J Tanner, AS Drawson, CJ Mushquash, AR Mushquash, D Mazmanian

    Harm reduction in gambling: a systematic review of industry strategies

    Addict Res Theory, 25 (2017), pp. 485-494, cited in The Lancet: https://www.sciencedirect.com/science/article/pii/S2468266722001372

    [25] National Lottery.co.uk

    [26] House of Lords Debate

    [27] Public Health Ireland

    [28] Mental Health.org

    [29] Money & Mental Health.org

    [30] https://www.moneyandmentalhealth.org/mental-health-and-gambling/

    [31] https://pubmed.ncbi.nlm.nih.gov/16915003/

    [32] House of Lords Debate

    [33] Gambling Commission

    [34] House of Lords Debate

    [35] House of Lords Debate

    [36] Calvin Ayre.com

    [37] BMC: Health Inequalities Gambling

    [38] BMC Public Health is an open access, peer-reviewed journal that considers articles on the epidemiology of disease and the understanding of all aspects of public health.

    [39] Gov.uk: Gambling Related Harms

    [40]BMJ.

    [41]APG Gambling Inquiry

    [42] APPG Gambling

    [43] Public Health Scotland

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