It used to be that high-stakes gambling required a trip to a casino. But with the rise of smartphones and the internet revolutionizing every part of our lives, placing bets is now faster and easier than ever. “Now the casino comes to us,” said Timothy Fong, an addiction psychiatrist and co-director of the UCLA Problem Gambling Studies Program.

And it’s not just traditional casino games — new forms of online gambling are emerging all the time, from sports betting to wagering on stocks and elections; there are even video games with gambling elements. This accessibility has fueled a rapid growth of the global gambling industry, according to participants at a forum held at Harvard University Jan. 23.

In 2018 the U.S. Supreme Court struck down the federal ban on sports betting, enabling individual states to legalize sports betting. Since then, 38 states, as well as Washington D.C. and Puerto Rico, have made sports betting legal (Utah, California and Texas are among the holdouts.) Today, some form of gambling is permitted in more than 80% of countries, and consumer losses are projected to reach $700 billion by 2028, according to The Lancet Public Health Commission on Gambling.

The growth of the industry is also a growing concern among public health experts. About 2 million people in the United States struggle with a gambling addiction, according to the National Council of Problem Gambling. In the past three years, the risk of gambling addiction grew by 30%, the organization says.

“We see the expansion of gambling activity not only on our phones, but in our real lives to the point that gambling is not only endemic, but it’s so much part of our daily lives that it has changed the fabric of what we do to our body, our brains and our minds,” said Fong, who spoke at the Harvard event.

Problem gambling is a public health issue, the panelists agreed, that demands public health solutions.

Is gambling addiction a disorder?

Gambling, in various forms, has existed for as long as humans have, and at its core gambling involves “putting something of value, usually money or time, on an event of uncertain outcome in order to win a larger reward,” according to Fong.

In recent years, the impact of the gambling industry has been amplified, largely by its convergence with financial and tech industries. This fusion creates a seamless online experience, offering instant gratification and the ability to place bets anywhere and anytime with just a tap.

“It’s definitely much more harmful than the usual other kinds of traditional gambling that people indulge in,” said Shekhar Saxena, professor of global health at the Harvard T.H. Chan School of Public Health. “It’s continuous, it’s intense, and it can be financially — and also physically and mentally — extremely harmful.” Online gambling can be 10 times more harmful than other forms of gambling, according to Saxena.

For some people, recreational gambling can be an occasional part of life without lasting harm. However, online accessibility has made it easier for recreational gambling to evolve into “early problem gambling,” as Fong describes it, leading to behaviors like lying or overspending —similar to early signs of alcohol abuse disorder.

Gambling addiction, or gambling disorder, is recognized by the medical community as an addictive behavior with biological and psychological risk factors similar to other addictions. Fong identifies it this way: “ongoing, continued engagement in gambling activities, despite harmful consequences.”

Unlike traditional gambling in social settings, online gambling often occurs in isolation, making it harder for others to recognize addictive patterns. This isolation exacerbates mental health challenges and allows issues to escalate unnoticed.

But even recreational gamblers who don’t have a gambling disorder and may be deemed to have a “safe” relationship with gambling are at risk, research shows. “When you put (on) a public health lens, what you see is that those individuals have higher rates of obesity, consuming alcohol at higher rates, and using prescription drugs at a higher rate,” said Victor Ortiz, who leads the Office of Problem Gambling Services for the Commonwealth of Massachusetts.

Studies show that online gamblers, particularly those who use multiple sites, have the highest rates of harm. “The ones with the highest rates are lying in bed at night on their iPad while their partner’s asleep,” said Lia Nower, director of Rutgers Center for Gambling Studies. This isolation allows addiction to worsen unnoticed, often exacerbating anxiety, depression and other destructive behaviors.

“It is not a disease of willpower, it’s not a disease of morality, it’s not a condition that people want to fall into,” Fong said. “It’s a condition of deep shame and really harmful consequences to the body, the brain, the mind and the spirit.”

Who is at risk for gambling addiction?

Teens and young adults are especially vulnerable, according Nower, who said they are often targeted with advertising designed to nudge them into using social sports wagering apps and then “triage” them into sports betting for money.

“And what we know is the longer someone plays and the more intensely they play over time, the higher the rates of problem gambling,” Nower said. “We are starting people much younger; we are anticipating there are going to be more problems.”

In Massachusetts, for instance, over the past decade, about 46% of middle and high school students have gambled each previous year, according to Ortiz, even though you have to be 18 to play the lottery and 21 to gamble at a casino.

Research has consistently pointed to two major risk factors that shift people from social stages of gambling to a more problematic scale — low education and economic status. But with the rise of sports betting, Ortiz noted, individuals of higher economic status and education are now susceptible to the same risks.

And parents are getting alarmed. Ortiz says his office has gotten calls from parents who are increasingly concerned about the gambling ads their kids are exposed to. “We’re getting more and more calls from individuals who are experiencing significant distress who are not our typical callers,” he said.

How to mitigate risks of online gambling

Treatment of gambling addiction often requires a combination of biological, psychological and social interventions, according to Fong. Some medications can help reduce gambling urges, and psychotherapy can aid in managing impulses. Restoring a sense of connection and purpose can also help. “The longer you stay in professional treatment, the better you do,” Fong said, noting that California has a state-funded treatment program.

But the field of gambling still lacks the research and awareness that exists around other public health issues such as tobacco or alcohol use. Advocacy groups for gambling reform are sparse, making it harder to generate public pressure for change, the panelists said. Families often conceal gambling-related problems due to stigma, which limits public understanding of the societal harm.

On a broader scale, gambling regulations vary widely across states. Advertising remains poorly regulated, and some casinos and online gambling platforms operate with minimal oversight, according to the panelists.

To rein in the explosion of digital gambling and its potential harms, Nower is advocating for a federal regulatory agency, similar to efforts to combat other substances like tobacco and alcohol. Other panelists advocated for stricter regulation of gambling ads.

Nower would like to see more corporate and federal regulations, such as an “opt out” vs. “opt in” system that would allow online gamblers to set limits on their time and how much money they deposit and lose. “I’m a big proponent of affordability guidelines, which put the onus on the gambling companies to assure us that this person is not spending more than they can afford,” she said. “And all of these things would have to be prescribed federally.”

But regulations around gambling often struggle to keep up with the speed at which new technologies are emerging. “So many times the technology is moving exponentially way faster than the governments can respond to, or that the public can respond to,” Fong said, noting that Congress is currently reviewing two gambling-related bills. The GRIT Act would allocate 50% of federal sports excise tax revenue to gambling addiction treatment and research. The SAFE Bet Act would require states with sports betting to enforce federal standards on advertising, affordability, and artificial intelligence. ” The public health framing is talking about the environment in which people live … and the kind of incentives that are there,” said Saxena. “Yes, people have some responsibility, but it’s the environment, it’s the technological environment, the social environment, and the economic environment in which people live.”

Spreading awareness in schools — dispelling the stigma around gambling and understanding its harms — should begin in grade school, according to Fong. But adults need this education, too. “This starts with re-educating adults, teachers, coaches, parents,” Nower said.

Massachusetts was one of the last states in the country to get a casino, Ortiz said, which allowed the legislature to learn from other states about best practices and allocate sufficient resources for mitigating solutions to gambling problems. Thanks to these resources, the Office of Problem Gambling Services for the Commonwealth of Massachusetts has been building out a public health model in combating gambling problems.

Is responsible gambling possible? The industry and the tech companies want you to believe so, but the experts at the Harvard panel were skeptical. “(Online gambling) has to be regulated just like food safety, air quality, water quality, because it is an issue of public health,” Fong said.