Commentary on Jonsson et al. (2020): The need for gambling public health policies and action

Effective prevention and harm reduction interventions will reduce gambling revenue. Their implementation will require mandatory measures and rigorous enforcement. This is unlikely unless gambling-related harm is firmly placed on national and international public health agendas. The well-designed study by Jonsson and colleagues [1] is one of few demonstrating longer-term effects from a responsible gambling (RG) intervention. This commentary considers the potential for interventions of this type to be more widely introduced and their capacity to reduce gambling-related harm. Gambling-related harm constitutes a significant public health challenge. Burden-of-disease studies suggest this harm exceeds that of drug dependence and some chronic physical illnesses, and is disproportionately experienced by disadvantaged and marginalised groups [2-4]. Most countries regulate gambling and governments, and gambling operators and other organisations have introduced measures to assist problem gamblers and promote RG. However, for the most part, their application is partial and/or perfunctory, and governments have not introduced effective regulatory and public health measures [5-7]. Reviews of government and industry strategies conclude that although a number of measures may have partial effectiveness, research quality is poor and the evidence base is weak [8, 9]. Most studies involve individual-level interventions and research has not assessed differential effects across demographic groups [10]. Reviews indicate that the most commonly implemented interventions are those least likely to be effective [10, 11]. It has been argued that failure to introduce more effective policies and measures is largely attributable to conflicts involved when the state is the gambling provider (directly or by permitting other providers), the regulator, and a significant beneficiary [5, 12]. A major tension is that problem gamblers and many others experiencing significant harm are responsible for a large proportion of gambling revenue. Effective prevention will inevitably result in reduced revenue for governments, gambling providers, and community organisations. During the past 15 years, the Reno model (RM) has played a major part in shaping the policy and the adoption of RG measures [5, 13]. The RM has been challenged on the grounds that it focusses on problem gamblers and individual responsibility, fails to take account of the full extent of gambling-related harm, promotes largely ineffective interventions, deflects attention from wider political, industry and social determinants of harm, and acts as a barrier to the introduction of legislative, regulatory, and public health remedies [5]. In short, RG interventions are supposedly more about giving the impression that consumer protection is being provided than actually reducing harm. While Jonsson and colleagues cautiously interpreted their findings and called for replication, the study demonstrated that a brief intervention could be embedded in a gambling provider's (Norsk Tipping) operations and significantly reduce the gambling expenditure of the top 0.5% of spenders. Although not assessed, given the strong association between expenditure and gambling harm, it is likely that a substantial proportion of participants will have been experiencing gambling-related harm [14, 15]. Although there was a 30% reduction in gambling expenditure in the telephone intervention group relative to 7% in the control, 94% of participants continued to gamble a year later and their average annual expenditure remained very high (approximately US $5600 per annum). As the study authors indicate, this level of expenditure greatly exceeds purported low risk gambling limits, and it is not known what impact the reduction had on the prevalence of gambling-related harm, including problem gambling. The finding that the intervention did not reduce Norsk Tipping's customer base will no doubt be viewed favourably by the company. However, substantially reduced expenditure among top spenders is unlikely to be regarded similarly. Although the intervention's effect on gambling-related harm is unknown, effective interventions will undoubtedly reduce gambling revenue. RG measures that involve a large measure of consumer choice, such as voluntary pre-commitment, generally have limited impact [5, 11]. It is highly likely that significant harm reduction will require more universal and mandatory engagement, especially in relation to more potent gambling forms such as electronic gaming machines. I agree with the conclusion of Jonsson et al. that although the technical evolution of gambling increasingly provides the means by which effective duty of care can be provided, this is unlikely to happen unless it is formally mandated and enforced. For this to happen, legislators will need to recognise the magnitude of gambling-related harm and the value of developing comprehensive policies and measures to address it. Gambling will need to be formally placed on international and national public health agendas. None The author acknowledges Dr. Giulia Lowe for assistance in formatting, proofing, and submitting the commentary.