Dr Frank Atherton, Chief Medical Officer for Wales – Written evidence (GAM0006)

Summary of response

1. The Gambling Act 2005 has had unintended consequences in the growth of gambling and has led to an increase in gambling-related harm. The harm caused by gambling is unequal in distribution, with those who are economically inactive and living in deprived areas suffering the most harm. It is time to rebalance the economic benefits of gambling by applying a public health approach to the issue along with a precautionary approach to protect children from the harms and potential harms from gambling. There is a clear risk to our younger generation who are exposed to gambling-type behaviours from an early age through online gaming and high levels of advertisements accessed via a range of media channels. 

2. The Gambling Act 2005 needs to be amended to: ensure it reflects on all forms of gambling, including online and gambling-type behaviours within games; make operators responsible for under-age gambling; and place statutory restrictions on where and how gambling products may be advertised, particularly around sports, as the impact of advertising cannot simply be controlled through codes that aim to prevent the appeal of adverts to children as their impact is more nuanced then that. There perhaps need to be a complete review of the gaming machine categories to ensure they are fit for purpose given the changes in the market since they were introduced. Research into the impact of under-18 use of Category D games machines and prediction of future behaviours would inform policy here.

3. Additionally, only a statutory levy can ensure a consistent and adequate level of funding is received to properly support harm minimisation, prevention, evidence-based treatment options and research into gambling-related harm. The services currently available are insufficient and better evidence on what works in practise is needed. A longitudinal study to explore the mobility in and out of the problem gambler category identified in population surveys would help to inform the factors causing gamblers to become problem gamblers and why some problem gamblers relapse, thus informing policy options. There is some evidence of associations between online gaming and gambling addiction but further research is needed to explore whether a causational relationship exists. The blurring of the lines between online gaming and gambling needs to be resolved.

Questions

The Gambling Act 2005

1. Are the three primary aims of the Gambling Act 2005 (to prevent gambling from being a source of crime or disorder, to ensure that gambling is conducted in a fair and open way, and to protect children and other vulnerable persons from being harmed or exploited by gambling) being upheld?

1. The Gambling Act 2005 has had unintended consequences in the growth of gambling and has led to an increase in gambling-related harm. The harm caused by gambling is unequal in distribution, with those who are economically inactive and living in deprived areas suffering the most harm.[1] The Welsh Government added questions on gambling in the Health Behaviour in School-aged Children/School Health Research Network survey added during 2017-18; data from this survey show that 13% of adolescents in Wales had spent money on gambling in the last seven days. Among the gambling activities most frequently reported were fruit/slot machines (5%), playing Lotto (3%), National Lottery Scratchcards (3%); playing machines in a betting shop and other gambling machines, betting in a betting shop,  National Lottery instant win games (internet) and any other National Lottery games were also reported but at lower levels. Adolescents reporting gambling in the past seven days increased with age, from 11% in year 7 to 17% by year 11.[2] It has been proposed that adolescent gambling is a high-risk behaviour, similar to alcohol, substance or tobacco use and unprotected sexual activity.[3]

2. It is time to rebalance the economic benefits of gambling by applying a public health approach to the issue. This has been understood in many countries across the world, including Canada, New Zealand and Australia, where such an approach has already been adopted.

2. What changes, if any, are required to bring the Act up to date with new technology and the latest knowledge about how gambling harm is distributed?

3. The Gambling Act 2005 needs, in particular, to be amended to address the rise in on-line gambling, provide tighter restrictions on advertising and broaden the definition of ‘gambling’ to bring the gambling-type behaviours within gaming into its jurisdiction to address that overlap.

4. The primary aims of the Gambling Act 2005 should also be amended to require that children are prohibited from gambling, rather than simply protected from being harmed or exploited.

3. Is gambling well regulated, including the licensing regime for both on- and off-shore operations? How successfully do the Gambling Commission, local authorities and others enforce licensing conditions including age verification? What might be learned from comparisons with other regulators and jurisdictions?

5. There is room for improvement here. Survey data from Wales show that under-18s are engaging in gambling activities[4] therefore age-verification checks are clearly not robust enough. The permission of gaming machines through alcohol licences should be reviewed given the results of test purchase data, published by the Gambling Commission in 2018, which showed an 89% failure rate to prevent children accessing 18+ gaming machines in pubs.[5] As far as is feasible, off-shore operations should be subject to the same requirements as on-shore operations.

4. Should gambling operators have a legal duty of care to their customers?

6. Yes; as should any responsible provider of goods or services. They should also have a legal duty to prevent underage gambling; this should be linked to their conditions of licence.

Social and economic impact

5. What are the social and economic costs of gambling? These might include costs associated with poor health and hospital inpatient services; welfare and employment costs; the cost of benefit claims; lost tax receipts; housing costs through statutory homelessness applications; and criminal justice costs.

7. The harms caused by gambling for the individual include anxiety, stress, depression, and alcohol and substance misuse[6]. These factors are likely to have a wider impact on family and friends. Further family problems can include ‘money troubles’ and family breakdown, as well as neglect and violence towards any partner or children. There are higher rates of separation and divorce among problem gamblers compared to the general population[7]. Further impacts of gambling include the inability to function at work, and financial problems which can lead to homelessness[8]. The harms from gambling to wider society include fraud, theft, loss of productivity in the workforce, and the cost of treating this addiction[9]. Gambling harm not only affects the individual.

8. The cost to society of gambling is hotly debated and, while there is no definitive sum which can be attributed to the cost of gambling in the UK, the Institute for Public Policy Research estimated the societal cost of problem gambling in 2016. Due to limitations in the data, these findings should be taken as an illustrative estimate of the excess costs incurred beyond those which are incurred by otherwise similar people. This study does not determine the causality between problem gambling and the incurrence of cost. The estimated excess cost of gambling for Wales is between £40 million and £70 million[10], which includes estimates for primary care (mental health) services, secondary mental health services, hospital inpatient services, Job Seekers Allowance claimant costs, lost labour tax receipts, statutory homelessness applications, and incarcerations. The costs listed represent those where data are available and is not an exhaustive list.

9. It has been reported that people who identified themselves as problem gamblers are twice as likely to consult their GP for mental health concerns, five times as likely to be hospital inpatients, and eight times as likely to access psychological counselling when compared with people who do not identify as problem gamblers[11].

6. What are the social and economic benefits of gambling? How can they be measured and assessed?

10. Gambling is a widespread and socially acceptable activity in the UK. It can provide social spaces for people to meet, and is enjoyed as a recreational activity by many. People can experience excitement when placing a bet, heightened pleasure watching a sporting event, and a thrill if they win. The gambling industry also offers employment and leisure opportunities and other social and economic benefits. Tax revenues are considerable in the UK: in 2017 this amounted to £2.7 billion[12]. However, the economic benefits of gambling need to be balanced against the social and health harms to people who gamble, their family, friends and wider society. While most people who participate in gambling activities do so without any significant problems, for others gambling is problematic; causing damage to their health and to wider society.

11. The benefits and harms experienced from gambling are variable. For example, a person who has a good income and plays the lottery once a week may experience little harm and some pleasure from playing the lottery. However, a person on a limited income who gambles to try and improve their financial position but experiences significant losses may experience a great deal of harm and little pleasure. Not all gambling exposes people to the same level of gambling harm. Research has indicated some forms of gambling are associated with higher levels of gambling-related harm[13],[14] but causality has not been proven. The complexity of gambling means that individuals experiencing severe harm from gambling often gamble using several different products and channels[15]. At a population level, there are lots of people experiencing small amounts of harm from gambling, and a small number of people that experience high levels of harm[16].

Levy

7. Is the money raised by the levy adequate to meet the current needs for research, education and treatment? How effective is the voluntary levy? Would a mandatory levy or other alternative arrangement be more productive and effective? How should income raised by a levy be spent, and how should the outcome be monitored? What might be learned from international comparisons?

12.                                                                                                                                                                                                                                                    At present, the monies raised are inadequate to meet the current needs for research, education and treatment. Due to their voluntary and irregular nature it is difficult for recipients to plan, budget and forecast their spending. In addition, Government has little control or influence where the contributions are directed. Ultimately, only a statutory levy can ensure a consistent and adequate level of funding is received to meet these aims and I therefore fully support this approach. Any monies received, whether voluntarily or through a mandatory levy should be used to support harm minimisation, prevention, evidence-based treatment options and research into gambling-related harm. The Gambling Commission should be responsible for auditing the monies received and spent to ensure full transparency and accountability. This information should be included in their annual report. Government, including the devolved governments, should be consulted on and approve an overarching plan on how the contributions received are spent. 

13.                                                                                                                                                                                                                                                    In New Zealand, the ‘problem gambling levy’ is set under the Gambling Act 2003 to reimburse the Government for the costs of the problem gambling integrated strategy to prevent and minimise gambling harm. The levy is collected on the profits of New Zealand’s four main gambling operators: gaming machines in pubs and clubs, casinos, the New Zealand Racing Board and the New Zealand Lotteries Commission. The levy is set every 3 years, with the formula used for calculating the levy rates for each sector specified by the Gambling Act 2003. The levy is calculated using rates of player expenditure (losses) on each gambling subsector and rates of client presentations to problem gambling services attributable to each gambling subsector – so reflects money lost and associated harm. The Levy is reviewed every 3 years. For 2013-16 – the levy ranged from 0.3% for the Lotteries Commission to 1.3% for Gaming Machine operators.

Research

8. How might we improve the quality and timeliness of research in the UK? What changes, if any, should be made to the current arrangements for funding, commissioning and evaluating research in the UK? What might be learned from international comparisons?

14. The Gambling Commission’s new national strategy suggests the need for an independent research hub. I agree that there is a need to co-ordinate research efforts across the UK to avoid overlap/duplication and to ensure future research addresses the existing gaps in knowledge. This could be achieved through a research forum, hosted by the Gambling Commission, which brings together key partners to agree a programme of research and monitor research outputs, including those from other countries.

9. If, as the Responsible Gambling Strategy Board (RGSB) has suggested, there is limited evidence on which to base sound decisions about gambling by children and young people, what steps should be taken to rectify this situation?

15. A precautionary approach should be adopted to protect children from the harms and potential harms from gambling; this should include harm caused by their own gambling and harm caused through the gambling of others. There is a clear risk to our younger generation who are exposed to gambling-type behaviours from an early age through online gaming and high levels of advertisements accessed via a range of media channels. 

16. More robust measures should therefore be in place to prevent underage gambling, this should include online gambling. The Gambling Act 2005 should be amended to make it a condition of licence that operators demonstrate the measures they have in place to prevent underage gambling. The definition of ‘gambling’ in the 2005 Act should be extended to include the gambling-type behaviours seen in gaming such as skins betting and loot boxes. Parents, guardians and those responsible for the health and wellbeing of children and young people should be made aware of the harms, and potential harms, of both online gaming and gambling. The minimum age for the National Lottery should be increased from 16 to 18 years old; this should be extended to all National Lottery products including those available online, scratchcards and the main draw.

Education

10. Is enough being done to provide effective public education about gambling? If not, what more should be done?

17. No. Prevention and education are key and more could be done via a public health approach to educate the public about gambling.

18. For children and young people, this can be addressed through the school curriculum in the first instance. In Wales, changes to the national curriculum are underway that make financial education a key element offering robust provision to help learners develop their financial skills. The new Personal and Social Education framework for 7-19 year olds includes the themes ‘Health and Emotional Wellbeing’ and ‘Preparing for Lifelong Learning’; these allow gambling as a topic to be picked up by learners when considering how lifestyle choices affect health and well-being and developing skills regarding managing money and budgeting. Advice to parents and carers has already been issued via the Welsh Government’s Hwb to address the risk to our younger generation of exposure to gambling-type behaviours through online gaming. 

19. Awareness of gambling treatment services should be increased; this should be via a public awareness campaign of the signs to look out (for both the individual and friends/family of gamblers) and where help can be sought. More awareness also needed about the available blocking software such as Gamban and banks/credit card providers that offer gambling-product blocks. Primary care workers and other frontline staff need to be educated in identifying those suffering from gambling-related harm and be made aware of the services available for referrals.

Treatment

11. Are the services available for the treatment and support of people at risk of being harmed by gambling sufficient and effective? How might they be improved? What steps might be taken to improve the uptake of treatment, particularly among groups who are most likely to experience harm from gambling and least likely to seek help?

20. The services currently available are insufficient and better evidence on what works in practise is needed. Treatment services in Wales that are funded by GamCare are in the process of being expanded through additional funding of the treatment provider Ara; however, whether this will fully address treatment needs in Wales is not yet known. The call by the National Institute for Health Research (NIHR) for evidence on which interventions are most effective and the consideration of treatment guidelines by the National Institute for Health and Care and Excellence (NICE) should go some way to address this issue.

21. Given the clear correlation between problem gambling and other health risk behaviours such as substance misuse and poor mental health, pathways between treatment services for these health issues should be improved and/or co-located to ensure a holistic, patient-centred approach. Behavioural treatment providers should be trained to identify gambling-related harm to improve links between services.  

22. Although population rates of problem gamblers are usually relatively stable (in Wales, the prevalence of problem gamblers was 1.1% of adults in 2015 and 0.8% in 2016[17]), there is some evidence to suggest that there are new problem gamblers every year and an element of relapse[18] [19] [20]. A longitudinal study to explore the mobility in and out of the problem gambler category identified in population surveys would help to inform the factors causing gamblers to become problem gamblers and why some problem gamblers relapse. Exploration of this issue would help to inform the approach taken in promoting treatment services and when intervention would be most successful.

23. International evidence shows higher rates of problem gambling amongst veterans than the general public but there is little UK data available[21]. Swansea University has been funded by the Forces in Mind Trust to undertake the first ever UK survey to understand and explore the levels of gambling participation and attitudes to gambling in ex-Service personnel[22].

12. What steps should be taken better to understand any link between suicide and gambling?

24.                     This is one of many research questions but something that needs addressing given findings from a recent review of the latest available evidence, which suggested that problem gamblers had elevated rates of suicidal thoughts, attempts and non-suicidal self-harm.[23] This review was based on 2007 data and so there is a clear need for more research in this area given the proliferation of gambling across the UK since that data was collected.

Advertising

13. The RGSB has said that by not taking action to limit the exposure of young people to gambling advertising “we are in danger of inadvertently conducting an uncontrolled social experiment on today’s youth, the outcome of which is uncertain but could be significant.” Do you agree? How should we make decisions about the regulation of gambling advertising? What might be learned from international comparisons?

25. Yes, I agree. The liberalisation of gambling as a result of the Gambling Act 2005 has resulted in huge increases in the volume of gambling advertising provided across the range of media channels. My 2017 Annual Report, Gambling with our Health[24] followed my return to the UK after four years of working in the Canadian public health system. On my return, I was immediately struck by the huge expansion of advertising for gambling products that had occurred in my absence. 

26. Codes of practice exist to control the content of gambling adverts[25] but do not address the general volume. The recently published Ipsos MORI Interim Synthesis Report on the effect of gambling marketing and advertising on children, young people and vulnerable adults[26] noted that exposure to the sheer volume of advertising and marketing led to perceptions of normalisation and, in time, legitimisation. I understand that the full synthesis report will explore this relationship further; these findings will be useful in the development of policy. I believe we should take greater regulatory control and place statutory restrictions on where and how gambling products may be advertised, similar to restrictions on the advertising of tobacco and alcohol.

Gambling and sport

14. Gambling is becoming an integral part of a growing number of sports, with increasingly close relationships between operators and sports clubs, leagues and broadcasters. What are the risks attached to this?

27. Gambling advertising and sponsorship within certain types of sport, predominantly football, has mostly replaced tobacco and alcohol advertising which was previously prolific in such arenas. Steps to address this close association should be a key area for action is it presents the risk of over-exposure to gambling adverts children and young people as well as vulnerable adults. 

28. The Remote Gambling Association (RGA) proposed ‘whistle-to-whistle’ advertising ban due to come into effect later this year is welcome but we cannot rely on the industry self-regulating and simply being responsible. In Australia, changes to broadcasting rules that came into effect in March 2018 that place more restrictions on live sport broadcasts between 5.00 am and 8.30 pm meaning that no gambling advertising or promotion of odds is permitted from five minutes before the published scheduled start of play, until five minutes after play, including during breaks.[27] 

29. The recently published Ipsos Mori report[28] found that gambling advertising in sport is a clear example of a category that can appeal to a wide audience (for example in the use of sports stars), including children, even if this is not the overall intention. In his review of tobacco product packaging, Sir Cyril Chantler talks of a ‘spill-over’ effect whereby packages that are designed to appeal to a young adult, also, albeit inadvertently, appeal to children[29]. I believe that a similarly plausible argument can be made in respect of gambling adverts, particularly when linked to sport; the impact of advertising in this space cannot simply be controlled through codes that aim to prevent the appeal of adverts to children as their impact is more nuanced then that.

Gambling by young people and children

15. How are new forms of technology, including social media, affecting children’s experiences of gambling? How are these experiences affecting gambling behaviour now, and how might they affect behaviour in the future?

30. There is some evidence of associations between online gaming and gambling addiction but further research is needed to explore whether a causational relationship exists. The blurring of the lines between online gaming and gambling needs to be resolved. Some games permits users to pay money to play games where they can win online prizes or tokens, which can then subsequently be sold online thus exposing children and young people to gambling-type behaviours before they are 18 years old.

31. In 2015, the Gambling Commission identified several risks associated with social gaming: problem gambling type risks - spending large amounts of time and/or money; transitional risks – social gaming increasing young people’s participation in real money gambling; and consumer protection type risks.[30]

32. The recent Ipsos Mori research found that adverts with no specific gambling reference feature particularly on social media where ‘content marketing’ was widely used to build brand loyalty rather than prompt a specific gamble (for example promoting a discussion about who are the best players in the league).[31] Given that over two-thirds of 12 to 15 year olds report using either Facebook or Instagram[32], this is an approach that has the potential for gambling operators to build their future customer base. 

16. The legal availability of certain forms of commercial gambling to under-18s in Great Britain is unusual by international standards and has been described as an ‘historical accident’. Should young people between 16 and 18 be able to purchase National Lottery products, including draw-based games, scratch cards and online instant wins?

33. I believe that the age of national lottery participation should be increased from 16 to 18 year olds and would like to see this across all products, including the national draw, online instant wins and scratchcards. The latest Health Behaviour in School-aged Children/School Health Research Network survey data show that the Lotto (3% of respondents) and National Lottery Scratchcards (3%) were among the gambling activities most frequently reported for adolescents to have participated in; National Lottery instant win games (internet) and any other National Lottery games were also reported but at lower levels.[33] 

34. We also need to better understand the extent to which some people are spending large proportions of their disposable income on National Lottery. Research in this area would help to inform the consideration of player protection options which could be used to support people in this position.

17. Should children be allowed to play Category D games machines (which include fruit machines, pushers and cranes)?

35. Research into the impact of under-18 use of Category D games machines and prediction of future behaviours needs to be undertaken to inform a response to this. There is anecdotal evidence of problem gamblers starting their gambling addiction through the use of penny slot machines and pushers. Given the recent lowering of the maximum stake for fixed odds betting terminals (Category B2 gaming machines), which has led to similar stakes and prizes in this category as compared to B3 and B3A machines, there perhaps need to be a complete review of the gaming machine categories.

5 August 2019