Betting your life on it

The United Kingdom is about to undergo one of the most radical changes of gambling legislation in its history. The new gambling bill will provide the British public with increased opportunities and access to gambling like they have never seen before. Gambling legislation will be revolutionised, and many of the tight restrictions on gambling dating back to the 1968 Gaming Act will be relaxed. As a result the number of casinos will increase, and Las Vegas type casinos will be introduced in resorts such as Blackpool. The deregulation of gambling is also coupled with the many new media in which people can gamble. As a consequence of technological innovation, people in the United Kingdom now have access to internet, interactive television, and mobile phone gambling. Given the expected explosion in gambling opportunities, is this something that the medical profession should be concerned about?

Gambling has not been traditionally viewed as a public health matter, and research into the health, social, and economic impacts of gambling is still in its infancy.1^–3 Just under 1% of the British population have a severe gambling problem, although the rate is about twice as high in adolescents, particularly as a result of problematic slot machine gambling.4 5 Pathological gambling is characterised by unrealistic optimism on the gambler's part. All bets are made in an effort to recoup losses. The result is that instead of cutting their losses, gamblers get deeper into debt, preoccupying them with gambling, and they are determined that a big win will repay their loans and solve all their problems. The social and health costs of problem gambling are large at both individual and societal levels. Personal costs can include irritability, extreme moodiness, problems with personal relationships (including divorce), absenteeism from work, neglect of family, and bankruptcy. Adverse health consequences for the gambler and his or her partner include depression, insomnia, intestinal disorders, migraine, and other stress related disorders.6 ^w1 In the United Kingdom, preliminary analysis of calls to the national gambling helpline also indicated that an important minority of callers reported health related consequences as a result of their gambling. These include depression, anxiety, stomach problems, and suicidal ideation.^w2

Other worrying trends relate to problem gambling and may have medical consequences. A recent study found that violence against intimate partners was predicted by pathological gambling in the perpetrator.7 A study of 286 women admitted to the emergency department at a University Hospital in Nebraska showed that a woman whose partner was a problem gambler was 10.5 times more likely to be a victim of violence from her partner than partners of a non-problem gambler. Furthermore, in 2003, the National Coalition Against Legalised Gambling reported that, with the opening of casinos in South Dakota, child abuse and domestic assaults rose by 42% and 80%, respectively.8 This was attributed to the increase in casino gambling.

Health related problems as a result of problem gambling can also result from withdrawal effects. Rosenthal and Lesieur 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.9 Results were also compared with the withdrawal effects from a control group that was dependent on substances. The authors concluded that pathological gamblers experienced more physical withdrawal effects when attempting to stop than did the control group.

Gambling behaviour clearly lies on a continuum from occasional gambling, regular gambling (once or twice a week) through to problem and pathological gambling. Problem gambling usually refers to gambling that the gamblers themselves find problematic, whereas pathological gambling usually refers to those who fulfil DSM criteria. However, pathological gambling is very much the hidden addiction. Unlike (say) alcoholism, there is no slurred speech and no stumbling into work. Furthermore, overt signs of problems often do not occur until late in the pathological gambler's career. If problem gambling is an addiction that can destroy families and have medical consequences then clearly medical professionals should be aware of the effects of gambling in just the same way that they are with other potentially addictive activities, such as drinking alcohol and smoking.

Problem gambling is very much a health issue that needs to be taken seriously by all in the medical profession. General practitioners routinely ask patients about smoking and drinking, but gambling is something that is not generally discussed.10 Problem gambling may be perceived as a grey area in the field of health, and it is therefore very easy to deny that those in the medical profession should be playing a part. If the main aim of practitioners is to ensure the health of their patients, then an awareness of gambling and the issues surrounding it should be an important part of basic knowledge.

Opportunities to gamble and access to gambling will increase because of impending deregulation. What has been shown clearly from research in other countries is that, for gambling, an increase in accessibility increases not only the number of regular gamblers but also the number of problem gamblers—although this may not be proportional.^w3 This means that not everyone is susceptible to developing gambling addictions, but it also means that the more the opportunities, the more the related problems. In Australia, Canada, and New Zealand, problem gambling has increased as a result of liberalisation.

Gambling is without doubt a health issue, and an urgent need exists to increase awareness in the medical and health professions about gambling related problems and to develop effective strategies to prevent and treat problem gambling.2 ^w4 The rapid expansion of gambling represents a serious public health concern, and medical practitioners also need to research the impact of gambling on vulnerable, at risk, and special populations. Inevitably, a small minority of people will become casualties of gambling directly as a result of the deregulation of gambling in the United Kingdom, and therefore help should be provided for the problem gamblers.