“I have a problem with gambling. There’s not enough of it.”
That was the admission from billionaire Steve Wynn, a major figure in the casino industry, speaking at a recent gambling research conference in (where else?) Las Vegas. And sure, it made for a good quote. But it’s also a rather glib dismissal of a serious issue that affects many thousands of people across the world.
The UK certainly has a problem with gambling. At least it has since 2007, when laws were changed to allow for huge growth in gambling opportunities and exposure. It has been hard to ignore the subsequent explosion in industry advertising, which increased by around 500% between 2007 and 2013. By contrast, you may have missed the increased numbers of high intensity electronic gambling machines, called Fixed-Odds Betting Terminals (FOBTs), which now occupy the high street (within betting shops) and allow punters to wager up to £100 every 20 seconds.
Yet Britain doesn’t have much insight into its problem with gambling. Compared to most other addictive behaviours, involving drugs or alcohol for example, gambling is largely ignored by health services and public health agencies. This is partly because gambling is a hidden concern. It does not manifest with physical warning signs. Indicators are usually visible in extreme cases only, and generally following major life crises such as extreme debt or relationship breakdown.
On top of this, the gambling industry has a surprisingly direct role in funding a great deal of the research into gambling, directly and indirectly through a third party organisation called GambleAware. It therefore plays a significant part in determining what we know about the nature of problems and possible solutions.
But people with gambling problems account for large amounts of industry revenue (up to 60% in dog racing). And this creates a clear conflict of interest for the gambling industry. Any success in reducing gambling problems is likely to reduce profits too.
So what of general practice, which is usually the first point of a contact with the healthcare system? Does it have a problem with gambling? Our recent research suggests it does. In a study of more than 1,000 patients in waiting rooms of general practices in the south-west of England, around one in 20 patients reported at least some degree of gambling problem. These levels were higher among young males and patients showing signs of depression or risky drinking. Around 7% of respondents reported problems among family members and were also likely to experience harms from gambling.
The findings suggest an issue for primary care that is hidden from healthcare providers. Gambling problems are strongly linked with poor mental health, suicidal tendencies and serious consequences for families through relationship problems and domestic violence. Gambling problems also create difficulties for the broader community through overuse of healthcare services. Primary care has important roles in responding to many such health concerns, including other addictive behaviours such as smoking and alcohol misuse and complex psycho-social issues such as domestic violence – it could have similar involvement in improving help-seeking and intervention for people with gambling problems.
Responding to a hidden addiction
There’s much more we need to know before we can determine the best ways in which general practice can help respond to gambling problems. There are different ways of identifying people who would benefit from help or intervention, such as universal screening or “case-finding” by questioning of patients demonstrating visible risk. Clinical responses can also vary and range from brief advice to onward referral. These may lead to very different equations in terms of the costs of interventions, including burdens on practitioners, and the balance of these compared to potential benefits.
In the absence of much attention to the health risks of gambling – and a lack of independent funding for research and interventions – it seems unlikely that there will be rapid progress in responding to gambling problems in general practice. But there is a need now for practitioners to be vigilant and inquire about potential problems. This is particularly important among young males or patients showing signs of depression, risky drinking or drug use, and financial difficulties.
As we’ve seen, the problem with gambling is that these issues are hidden from view. They have not been a priority when compared to health concerns that are more visibly obvious, such as obesity and alcohol misuse. GPs and practice nurses have an important part to play in putting these problems on the healthcare agenda.