Stronger global regulatory controls are needed to reduce the impact of commercial gambling on worldwide health and wellbeing, according to a new Lancet Public Health Commission on gambling.

The Commission brought together a multidisciplinary group of leading experts in gambling studies, public health, global health policy, risk control and regulatory policy, alongside contributors who have first-hand experience of gambling harms. After reviewing the literature, and figures generated from a systematic review and meta-analysis, the Commissioners concluded that ‘gambling poses a threat to public health, the control of which requires a substantial expansion and tightening of gambling industry regulation.’

Professor Heather Wardle, Co-Chair of the Commission from the University of Glasgow, explained the changing nature of gambling: “Most people think of a traditional Las Vegas casino or buying a lottery ticket when they think of gambling. They don’t think of large technology companies deploying a variety of techniques to get more people to engage more frequently with a commodity that can pose substantial risks to health, but this is the reality of gambling today.

“Anyone with a mobile phone now has access to what is essentially a casino in their pocket, 24 hours a day. Highly sophisticated marketing and technology make it easier to start, and harder to stop gambling, and many products now use design mechanics to encourage repeated and longer engagement. The global growth trajectory of this industry is phenomenal; collectively we need to wake up and take action. If we delay, gambling and gambling harms will become even more widely embedded as a global phenomenon and much harder to tackle”, she added.

The extent of gambling harms

A systematic review and meta-analysis conducted for the Commission estimates that approximately 448·7 million adults worldwide experience any risk gambling, where individuals experience at least one behavioural symptom or adverse personal, social or health consequence of gambling. Of these, an estimated 80 million adults experience gambling disorder or problematic gambling [1]. These estimates are likely to be conservative.

The new analysis also estimates that gambling disorder could affect 15·8% of the adults and 26·4% of the adolescents who gamble using online casino or slot products, and 8·9% of the adults and 16·3% of the adolescents who gamble using sports betting products. Online casino and online sports betting are two of the most rapidly expanding areas for commercial gambling globally.

Commercial gambling is clearly associated with financial losses and the risk of financial ruin, but it is also associated with physical and mental health problems, relationship and family breakdown, heightened risk of suicide and domestic violence, increased crime against property and people, and loss of employment.

The Commission report notes that this impact is not spread evenly through populations, and specific groups face an elevated risk of harms. These include children and adolescents who are routinely exposed to advertising of gambling products in ways that were unprecedented before the digital revolution. In addition, gambling is often embedded into the architecture of video games.

Speaking about those who are most vulnerable, Dr Kristiana Siste, Commissioner, the Universitas Indonesia, said: “We need to take action to protect children from the harms of gambling. We know that early exposure to gambling increases the risk of developing gambling disorders later in life, and children and adolescents are particularly vulnerable to the allure of easy money and the game-like designs of online gambling.”

Challenging the role of the gambling industry in protecting and promoting its interests

The Commission report describes how a complex ecosystem underlies how the commercial gambling sector promotes its products and protects its interests. This includes innovative digital marketing approaches rooted in deep surveillance to target consumers online, widespread sports and broadcast media sponsorship, and fintech. The Commission report also raises concerns about how the commercial gambling sector undermines legitimate science on the impact of gambling, reframes discussions about gambling to promote individual responsibility and consumer freedom, and influences political processes around gambling regulation.

Professor Malcolm Sparrow, Commissioner, Harvard Kennedy School, explains the need for increased regulation of gambling: “While the industry continues to promote gambling as harmless entertainment, countries and communities are experiencing rapidly increasing threats from gambling harms.”

The Commission urges policy makers to treat gambling as a public health issue, just as we treat other addictive and unhealthy commodities such as alcohol and tobacco. We call for policy makers to make protection from gambling-related harms the primary and dominant regulatory focus, and to insulate the policy making process more effectively from industry influence.”

Professor Malcolm Sparrow, Commissioner, Harvard Kennedy School

Commercial gambling risks exacerbating inequalities

Commercial gambling is available in over 80% of countries globally, with expansion escalating particularly quickly in lower- and middle-income countries, which often have a weak regulatory infrastructure to address this global industry and its harms. A heavy burden of harm falls on individuals who are already socially disadvantaged.

Given the widespread and escalating harms associated with gambling, the Commission report highlights multiple ways in which commercial gambling might seriously undermine progress towards UN Sustainable Development Goals. This includes hindering progress on key areas such as reducing inequality and poverty, improving gender equality, and improving health and well-being.

“Gambling disorder has evolved into a borderless crisis, affecting individuals and societies across the globe. Although gambling is illegal here in Indonesia, online gambling is prevalent and the number of transactions have exploded in recent years. The gambling products are provided from international servers, and our national law enforcement is unable to restrict access”, said Dr Siste.

“We will only be able to make progress through coordinated international efforts, combining global policy reform, cross-border cooperation, and collective harm reduction strategies”, she added.

In-country regulation is needed alongside international efforts

The Commission calls for effective gambling regulation to be put in place in all countries, irrespective of whether gambling is legally permitted. This should include reductions in population exposure and the availability of gambling, through prohibitions or restrictions on access, promotion, marketing, and sponsorship. The Commission recommendations also ask for the provision of affordable, universal support and treatment for gambling harms alongside well-resourced social marketing and awareness campaigns to raise awareness of harms.

Dr Charles Livingstone, Commissioner, Monash University, described the situation in Australia: “Australians spend the most per head on gambling worldwide, $AUD 1,555 per adult per year [2]. Both online betting, boosted by close connection with football and other sports, and electronic gaming machine gambling continues to grow at a rapid pace here, despite escalating concerns of ordinary people and the voice of those affected by gambling harms becoming more prominent.

“There is a desire for change and to rightly treat gambling as a serious public health issue in Australia, given the extent and nature of harm. Yet extensive evidence of dishonest and illegal behaviour by casino operators requires Herculean efforts to properly regulate these entities, and the commercial gambling industry more broadly have been shown to be heavily resistant to reform efforts”, he concluded.

The Commission stresses that global leadership will be needed to ensure gambling is prioritised as a global public health issue. It asks that UN entities, particularly the WHO, and intergovernmental organisations incorporate a focus on gambling harms into their strategies and workplans for improving health and wellbeing broadly.

A new international alliance should also be developed to advocate to reduce gambling harms and provide leadership, made up of people with lived experience of gambling harms, professional organisations and researchers. The Commission also calls for a World Health Assembly resolution on the public health dimensions of gambling.