Gambling Position Statement Gambling has been identified as one of PHAIWA’s priority areas, given its impact on the health of Australia’s population, and the wider effects that gambling has on Australian society.

Key Facts     

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Gambling is a public health issue with significant health and social impacts, at both the individual, family and community level; 1 70% of Australians report participating in some form of gambling annually;2 80% of adolescents engage in a form of gambling by the age of 18;3 Gambling has been shown to be of higher prevalence in Indigenous populations compared to the general population;4 Problem gambling is associated with mental health and substance abuse disorders, resulting in relationship breakdowns including family conflict and intimate partner violence, financial stress with high rates of bankruptcy, and reduced quality of life;5, 6 Online gambling in sport is becoming more prevalent with increasing user strategies that appeal to young people and in particular young males.7

Literature Review Problem Gambling overview Gambling is a recognised public health issue, with both individual and social impacts. With the diversification of gambling methods in Australia over recent decades, and its associated range of marketing strategies to promote gambling products, it is appropriate that public health policies address this area. The literature recognises the importance of incorporating public health measures through the development of a public health framework to address these concerns. 1 Problem gambling has been identified as an emerging public health issue, 8 with significant health and social impacts, at the individual, family and community level. Many Australians gamble each year, with 70% of Australians reporting participating in some form of gambling. 2 Problem gambling is estimated to affect 0.7% of the Australian adult population, and a further 1.7% is estimated to be at moderate risk for problem gambling. 2 It has also been estimated that up to 80% of adolescents engage in a form of gambling by the age of 18, 3 and the effects on young people are of particular concern. 8 Problem gambling has been defined as being “…characterised by difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community.” 9 The modern gambling environment has been heavily influenced by the gambling industry which has greatly increased gambling consumption. Factors promoting this include: July 2015

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the move to large commercial operations, the development of sophisticated technologies to attract players, and the adaptation across the global sector to attract vulnerable populations, all of which have eventuated in gambling practices becoming omnipresent within communities. 1

The gambling industry experienced substantial growth with liberalisation of gaming machines during the 1990s, followed by stabilisation and growth in keeping with other industries. 2 Since then, the gambling industry has created a pervasive online presence which is impacting on overall gambling involvement, with a recent study showing an increase in interactive gambling, with 64.3% of Australian adults reporting participation in online gambling over a 12 month period. 10 Problem gambling has become a product of the environment, with higher rates of problem gambling occurring in areas of increased facilities, and where ease of access to gambling products exists. 11 This is intertwined with the conflicts of interest from financial benefits which governments and community organisations have with the gambling sector. 1 There is a strong financial connection with government, who are involved in industry regulation, delivery of treatment services and implementing public health strategies to combat gambling issues. 12 The risks of problem gambling are low for gambling forms relating to lotteries and scratchies, however these increase substantially with gambling on table games, wagering and particularly the use of electronic gaming machines. 2 Electronic gaming machines are available across all states and territories except for Western Australia, where they are not permitted outside of the casino, and have been associated with the highest gambling related problems. 11

Gambling in Western Australia In comparison to the other States and Territories, Western Australia holds a unique position within the gambling landscape due to WA’s effective ban on electronic gaming machines outside the casino, and the support of this policy measure by successive governments. This has resulted in lower rates of problem gambling per capita when compared to Victoria and South Australia. 13 Whilst Western Australia has lower rates of both problem gambling and gambling generally, the Productivity Commission warns against direct comparison of statistics by state and jurisdiction given that data is derived from various sources. 2 These same findings were represented in data released by the ABS in 2000, for gambling expenditure per head of adult population between 1997-1998, with Western Australia having the lowest average expenditure ($528 per adult), next to Tasmania ($508 per adult), and New South Wales rating the highest ($963 per adult). 14 This lower expenditure on gambling products in Western Australia is not reflected in online gambling. There is substantial government involvement in, and revenue from, gambling in Western Australia, with the government owned TAB spread across the state.

The health and social consequences of problem gambling The impact of gambling on public health is often under recognised despite the far reaching consequences of problem gambling, with implications for the individual, families and society. Problem gambling is associated with mental health and substance abuse disorders, resulting in relationship breakdowns including family conflict and intimate partner violence, financial stress with high rates of bankruptcy, and reduced quality of life.5, 6 The presence of comorbid disorders is substantial, with alcohol misuse, depression, anxiety, suicidal ideation, nicotine dependence, and substance use being higher in problem gamblers compared to the general population. 15 A systematic review and metaJuly 2015

analysis of problem and pathological gamblers has shown that this population has high rates of other comorbid disorders, with the highest prevalence seen for nicotine dependence, substance use disorder, any type of mood disorder, and any type of anxiety disorder. 16 Problem gambling is overrepresented in certain groups, including people who have experienced a significant relationship breakdown, are unemployed, of lower socioeconomic status, young people, or from an environment of drug or alcohol misuse or gambling problems. 11 The Australian Medical Association has recommended that screening for problem gambling and other comorbidities are included as part of a lifestyle risk assessment by general practitioners, 17 with screening extended to include psychological impacts on family members also recommended by experts. 5 The impacts of gambling on family members is significant, with partners and children experiencing a range of emotional, physical and behavioural effects, 6 with a substantial number of people accessing gambling support services being family members of problem gamblers. 2 People who have a family member with problem gambling are more likely to develop gambling problems themselves, with children whose parents are problem gamblers being at 2 to 4 times greater risk of developing gambling problems than children to parents who do not gamble. 18 Strategies to prevent gambling through raising awareness of problem gambling can be effective, but need to be sustained or repeated often, and insufficient evaluation of these methods exists. 8, 19 Problem gambling awareness programs can increase the number of problem gamblers accessing treatment. 19 The provision of counselling and support services for gambling are effective for reducing gambling and gambling related problems. 2 Whilst many prevention strategies are utilised and available, little is known about the individual effectiveness of these strategies. 19

Gambling and Young People Regulating the promotion of gambling to young people is difficult, given the wide range of media to which young people are exposed, and the powerful influence that advertising has on this group. 20 An Australian study identified gambling amongst young people aged 11-19 years old in the ACT, reported that 70% of adolescents had gambled in the previous 12 months, with 10% gambling at least weekly. 21 It estimated that 4% of adolescents could be categorised as problem gamblers according to DSM-IV criteria, with males and Indigenous young people overrepresented within this high risk group. This higher rate of problem gambling in young people has also been reflected in several studies overseas. 22 Gambling activities in this study were identified as private card games, scratchie tickets, and betting on racing and sporting events as the most popular forms to participate in, with the majority of participants who had gambled, taking part in two to four forms of gambling. 21 It has been shown that gambling in young people signifies a certain amount of risk taking, and has been linked to increased rates of risk taking activities including substance use and alcohol use, as well as physical and mental health disorders including depression, suicidal ideation and attempt, and anxiety. 8, 21

Gambling in Indigenous people Gambling has been shown to be of higher prevalence in Indigenous populations compared to the general population. 4 An analysis of the 2002 National Aboriginal and Torres Strait Islander Social Survey, and the 2002 General Social Survey, identified that gambling-related problems were two to five times higher in non-remote areas in Indigenous populations when compared to the general population in Australia. 23 In remote areas, this was found to be significantly higher. 23, 24 As well as taking part in the usual forms of July 2015

gambling, Indigenous Australian communities have historically undertaken card games, a form of unregulated gambling, which has been shown to have negative effects on communities. 23-25 Adequately addressing gambling problems through the use of mainstream interventions within Indigenous communities usually fails, due to the unique social, cultural and familial influences on gambling within these populations. 4

Interactive (Online) Gambling In Australia, the Interactive Gambling Act 2001 legislates against interactive gambling services being provided to the Australian population, however Australian residents can legally play online poker or casino games, or engage in online sports betting. 26 This liberalisation of online sports betting is of particular concern, given the integration of marketing during live and televised sport, as further discussed below. The availability of online gambling increases the exposure of people to gambling, by providing more opportunities, and the ease and access to do so. 27 Australian research has shown that advertising is effective in increasing overall consumption of online gambling, by shifting land based gamblers to online forms, and encouraging online gamblers to gamble more often. 28 The Productivity Commission Report (2010) calls for greater liberalisation of legislation surrounding online gaming forms, on the basis of providing consumer protection and retaining economic benefits in Australia. 26 The concern in this area include Australia’s lack of experience in regards to regulating online gambling forms, the apparent lack of penalties for those who breach legislation or codes, the voluntary self-regulation of gambling advertising, and the significant increase in the promotion of online gambling.

Gambling in Sport and Marketing Marketing of sports betting is more noticeable than ever in Australia, with a range of strategies being employed including accessible online wagering sites, the use of social marketing tools, sports sponsorship, promotional products, online advertisements, the promotion of live odds at games, and strategic television based advertising promoting sports betting. 20 This reflects the rapid diversification of gambling, with sports wagering and its associated marketing practices showing rapid growth. 2 Gambling advertising has the potential to negate health promotion strategies and education activities. 2 Various Australian studies have reported the pervasive form of advertising related to sports wagering, notably in the AFL, due to the diverse range of platforms used to promote gambling related products. 2, 3 Sports sponsorship by the gambling industry results in frequent exposure to marketing during match telecasts, with on-site signage, advertisements during commercial breaks and logos on team uniforms being just a few of the tactics employed. 29 The ‘marketing mix’ of advertising, price, promotion, placement and product, has long been recognised in areas such as tobacco control, resulting in effective policies, however given the lack of research tailored towards the marketing of gambling products, there is a paucity of evidence and policies addressing this. 30 Policy pertaining to limiting the marketing of sports wagering in Australia varies between States, Territories and the Federal government, with particularly limited policy for the newly emerging aspect of online betting and social marketing. Sports wagering remains largely industry regulated, with the Australian Wagering Council who represent the major betting companies, highlighting its commitment to ensuring advertising is done in a ‘socially responsible manner’. 31 Voluntary driven guidelines for responsible marketing is insufficient. 20 As has been shown in areas such as tobacco, alcohol, and food, relying on industry-led regulation is destined to fail.32 July 2015

Key Advocacy Targets The role of public health advocacy in an emerging field such as gambling is vital; this would entail identifying best practice, key advocacy strategies, and exploring and establishing a framework that can be adapted and applied widely within this field. As has been shown within tobacco and alcohol, relying on industry-led regulation rather than public health driven policy is negligent. 32 The need for addressing gambling from a public health perspective is well recognised, 33 with the Productivity Commission advocating for a larger emphasis to be placed on gambling issues through a public health perspective rather than individual focus, 2 however limitations in available research prevent development of adequate policies. This is largely due to gambling being an industry driven problem which has only been addressed by a biomedical model until recently, during which time it has transitioned to a recognised public health issue. 11 It has been suggested that an ideal public health model would identify and combine the skills of campaign leaders with advocacy ‘process’ experts to aid the development of successful advocacy strategies. 34 PHAIWA recommends adopting the following key advocacy targets: 

Adopting a public health framework to address problem gambling

Addressing the following main areas: 

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Access o Reduce and regulate the availability of gambling products within the environment, as a means of influencing access and reducing problem gambling; 11 o Maintain the ban on poker machines outside of the Burswood casino in Western Australia; 19 Health promotion strategies o Raise public awareness about the negative effects of gambling and the signs of problem gambling through education and health promotion messages, including at points of gambling advertising; 2 o Increase public awareness of the negative effects of problem gambling within Indigenous populations, and improving supports within Indigenous communities; 24 o Regulate the advertising and marketing of products to vulnerable populations, specifically reducing the exposure of gambling amongst young people; 20 o Develop public awareness and warning messages independent of the gambling industry; o Increase funding for gambling related research in Western Australia; Harm minimisation strategies o Clearly display warnings for gambling products which can lead to potential harm; o Development of an overarching national regulatory body to address the issues associated with industry self-regulation, with a mutually agreed code of conduct; 35 o Regulate gambling advertising and sponsorship relating to sporting events and teams, including live broadcasts; July 2015

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Development of national guidelines, drawing on the experiences of other countries, and a regulatory body for online forms of gambling, particularly in the event of legalization of certain forms of gambling currently banned from being supplied from within Australia, such as online poker; 26 o Collaborate with professional health bodies to promote harm minimisation strategies; Treatment o Health professionals and counselling services should be vigilant about problem gambling, and screen high risk individuals for signs of problem gambling. 2, 17 o Policies and support services need to be wide reaching and encompass everyone who is adversely impacted on by problem gamblers through emotional, financial or health means. 2, 5

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14. Australian Bureau of Statistics. Gambling in Australia. Canberra; 2000 [Online]. Available at: http://www.abs.gov.au 15. Haw J, Holdsworth L, Nisbet S. Gambling and Co-Morbid Disorders. Melbourne: Prepared by the Centre for Gambling Education & Research at Southern Cross University for Gambling Research Australia; 2013 [Online]. Available at: http://www.gamblingresearch.org.au/home/research 16. Lorains FK, Cowlishaw S, Thomas SA. Prevalence of comorbid disorders in problem and pathological gambling: systematic review and meta-analysis of population surveys. Addiction. 2011; 106:490-498. 17. Australian Medical Association. AMA Position Statement: The Health Effects of Problem Gambling. Canberra; 2013 [Online]. [Accessed 16 April 2015]. Available at: https://ama.com.au/positionstatement/health-effects-problem-gambling-2013 18. Dowling NA, Jackson AC, Thomas SA, Frydenberg E. Children at Risk of Developing Problem Gambling. Melbourne: The Problem Gambling Research and Treatment Centre; 2010 [Online]. Available at: http://www.gamblingresearch.org.au/home/research 19. Williams R, West B, Simpson R. Prevention of problem gambling: A comprehensive review of the evidence. Ontario, Canada: Report prepared for the Ontario Problem Gambling Research Centre; 2007 [Online]. [Accessed 5 May 2015]. 20. Monaghan S, Derevensky J, Sklar A. Impact of gambling advertisements and marketing on children and adolescents: Policy recommendations to minimise harm. Journal of Gambling Issues. 2008; (22):252-274. 21. Delfabbro P, Lahn J, Grabosky P. Further Evidence Concerning the Prevalence of Adolescent Gambling and Problem Gambling in Australia: A Study of the ACT. International Gambling Studies. 2005; 5(2):209-228. 22. Derevensky J, Gupta R, Winters K. Prevalence Rates of Youth Gambling Problems: Are the Current Rates Inflated? Journal of Gambling Studies. 2003; 19(4):405-425. 23. Stevens M, Young M. Betting on the evidence: Reported gambling problems among the Indigenous population of the Northern Territory. Australian and New Zealand Journal of Public Health. 2009; 33(6):556-65. 24. Stevens M, Young M. Independent Correlates of Reported Gambling Problems Amongst Indigenous Australians. Social Indicators Research. 2010; 98:147-166. 25. Young M, Barnes T, Stevens M, Paterson M, Morris M. The Changing Landscape of Indigenous Gambling in Northern Australia: Current Knowledge and Future Directions. International Gambling Studies. 2007; 7(3):327-343. 26. Gainsbury S. Response to the Productivity Commission Inquiry Report into Gambling: Online gaming and the Interactive Gambling Act. Gambling Research Volume. 2010; 22(2):3-12. 27. LaBrie R, LaPlante D, Nelson S, Schumann A, Shaffer H. Assessing the Playing Field: A Prospective Longitudinal Study of Internet Sports Gambling Behaviour. Journal of Gambling Studies. 2007; 23:347362. 28. Hing N, Cherney L, Blaszczynski A, Gainsbury S, Lubman D. Do advertising and promotions for online gambling increase gambling consumption? An exploratory study. International Gambling Studies. 2014; 14(3):394-409. 29. Lamont M, Hing N, Gainsbury S. Gambling on sport sponsorship: A conceptual framework for research and regulatory review. Sport Management Review. 2011; 14:246-257. 30. Moodie C, Hastings G. Social Marketing and Problem Gambling: A Critical Perspective. Addiction. 2009; 104(5):697-698. 31. Daube M. Live sports odds ban: does the government's plan go far enough? ; 2013 [Available from: http://www.theconversation.com/live-sports-odds-ban-does-the-governments-plan-go-farenough-14661.

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32. Moodie R, Stuckler D, Monteiro C, Sheron N, Neal B, Thamarangsi T, et al. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. The Lancet. 2013; 381(9867):670-679. 33. Korn D, Gibbins R, Azmier J. Framing Public Policy Towards a Public Health Paradigm for Gambling. Journal of Gambling Studies. 2003; 19(2):235-256. 34. Christoffel KK. Public Health Advocacy: Process and Product. American Journal of Public Health. 2000; 90(5):722-6. 35. Public Health Association of Australia. Policy-at-a-glance - Gambling & Health Policy. 2011 [Online]. [Accessed 16 April 2015] Available at: http://www.phaa.net.au/documents/item/249

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