Gambling with the nation's health

Abstract

Decisions about building casinos in the UK have not given enough weight to the potential health effects, argue John Middleton and Farid Latif

In March the House of Lords threw out government proposals to build the UK's first Las Vegas-style super casino in Manchester and build 16 other casinos around the country.¹ This decision reflects polarised views about the costs and benefits of liberalised gambling in the United Kingdom, but the health dimension of the debate has been lacking.¹ The UK currently has a low prevalence of problem gamblers, estimated to be 0.6%.² By contrast the rate in the United States is about 2.8%, although rates vary across states. In New Jersey, the home of Atlantic City, the US's second largest casino resort, the prevalence of problem gambling is 4.2%.³

However, the UK's low rates seem likely to increase when the Gambling Act 2005 is implemented. The act will give the British public more access to gambling facilities than ever before. In the year after a casino was opened in Niagara, not only did gambling rise but the percentage of residents reporting two or more gambling problems rose from 2.5% to 4.4% and those having one or more problems increased from 9.6% to 12%.⁴

What is problem gambling?

Gambling refers to any game of chance or skills that involves a financial risk. Problem gambling is defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders as “persistent and recurrent maladaptive gambling behaviour that disrupts personal, family or vocational pursuits.”⁵ It describes a progressive disorder characterised by continuous or periodic loss of control over gambling; a preoccupation with gambling and money with which to gamble; irrational thinking; and continuation of the activity despite adverse consequences. This psychiatric definition focuses on impaired ability to control gambling behaviour; adverse social consequences that disrupt personal, family, or vocational pursuits; and tolerance (need to gamble with increasing amounts of money in order to achieve the desired excitement) as well as withdrawal. For a diagnosis of pathological gambling, the person's behaviour must satisfy at least five of the 10 criteria and not to be better accounted for by a manic episode.⁵

Gambling affects physical, mental, and social wellbeing as well as creating debt. The strategies used to gain more money to gamble have serious effects on many determinants of health and can cause marital conflict, child neglect, poor work performance, multiple addictions, stress related physical ailments, crime, and even suicide.⁶ Problem gamblers and pathological gamblers are more likely than others in the general population to have been divorced, had physical and psychological problems, lost a job, been receiving welfare benefits, been declared bankrupt, and been imprisoned.⁷

Problem gambling is also associated with juvenile delinquency and family problems.⁸ Adolescents who have high rates of gambling are far more likely to drink alcohol, smoke cigarettes, or consume drugs.⁹ Children of pathological gamblers are twice as likely to attempt suicide, have lower academic grades, and have higher rates of substance misuse than their peers.¹⁰ A Quebec study of college students found that 27% of pathological gamblers had attempted suicide compared with 7% of students with no gambling problem.¹⁰

Withdrawal effects can also cause problems. One study found that at least 65% of pathological gamblers reported at least one physical side effect during withdrawal, including insomnia, headaches, loss of appetite, physical weakness, heart racing, muscle aches, breathing difficulty, and chills.¹¹

Problem and pathological gamblers often turn to crime to support gambling habits when all other resources are exhausted. Studies show that two out of three pathological gamblers commit crimes to pay off debt or to continue gambling, although the majority of crimes are non-violent and include embezzlement, cheque forgery, stealing credit cards, tax evasion, fencing stolen goods, insurance fraud, bookmaking, or employee theft.¹⁰

Pathological gambling is also a predictor of violence against intimate partners.¹² A study of 286 women admitted to the emergency department at a university hospital in Nebraska showed that women whose partners were problem gamblers were 10.5 times more likely to be a victim of violence from their partner than women whose partners were not problem gamblers. Furthermore, in 2003, the National Coalition against Legalized Gambling reported that, with the opening of casinos in South Dakota, child abuse and domestic assaults rose by 42% and 80%, respectively.¹³ This was attributed to the increase in casino gambling.

Population effects

But most casino customers will not be compulsive or problem gamblers. The levels of problem gambling reflected in these studies suggest only a small minority are affected, although the resulting social effects may be wider. More pervasive, however, will be minor effects on large numbers of the population previously unexposed to casino gambling. The purpose of the enterprise is to take money off customers. Even the most generous of slot machines in working men's clubs pay back on average only 80% of the taking; for commercial enterprises the pay back is much less. So poor communities face a slow leakage of funds they can ill afford, with further overall impoverishment of their local economies.

Sandwell Council in the West Midlands has become the first in England to use the no casino resolution of the Gambling Act 2005 to prevent any new build casinos in the area. The decision was largely based on risk of poverty and related health consequences presented in the report of the director of public health.¹⁴ The act requires local authorities to have a statement of principles that covers their duty to prevent gambling becoming a source of crime and disorder, ensure gambling is conducted in a fair and open way, and protect children and other vulnerable people from gambling. While most local authorities seem to have looked at casino building as a regenerative opportunity, Sandwell has taken the view that any development is likely to further impoverish local people. Experience with national lotteries supports this view.

Lotteries tend to gather money from poor people to be spent on amusements for wealthy people.^{15 16} If a lottery widens inequalities of income it will have important implications for health, as shown by evidence of an association between inequality of income in industrialised countries and lower life expectancy.¹⁷ Much of the evidence on the effect of lottery sales comes from the United States. One study concluded that lotteries are “some what” regressive and the highest level of participation was among the middle income group.¹⁸ A large household study in Oregon found the middle income group to be the most frequent purchasers, but poor people spend a substantially higher proportion of household income on lottery tickets than the middle class and that lack of education was the strongest predictor of purchase.¹⁹ A time series analysis showed that lottery sales increase with increasing unemployment.²⁰ A study in New York showed that lotteries consume a high proportion of household income—4.4% among heavy users.²¹

Doctors' role

Problem gambling is an addiction that can destroy families and can have medical consequences. Medical professionals should be aware of it in just the same way they are with other potentially addictive activities, such as drinking alcohol and smoking. General practitioners routinely ask about smoking and drinking, but gambling is something not generally discussed. A possible doubling of problem gambling rates is unlikely to become apparent overnight, and health consequences are likely to be insidious. Many of the health consequences present at generalist services—general practices, accident and emergency departments, and mental health services. The UK has few specialist services available for problem gambling, and the demands on such services are likely to increase. ²²

The wider public health effects of an increase in gambling in the population are even more hidden but ultimately more damaging. Anything that makes the poor people in Britain even poorer, especially if they do not derive benefits in kind, will damage their health, further increasing inequality in health.

The UK government is reconsidering its policy and intends to bring forward new proposals for developing casinos next year. A prospective programme of properly funded assessment of health effects must be part of any new proposals.