Gambling and public health

Gavin is joined by Heather Wardle, Professor of Gambling Research and Policy at the University of Glasgow, and the lead commissioner on The Lancet Public Health’s Commission on Gambling, to discuss the rapid expansion of the global gambling industry and its profound public health implications. We chat online gambling, technological advancements, and increasing accessibility, and how they are transforming the gambling landscape, leading to widespread health harms.

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Transcript

Gavin: Hello and welcome to the Lancet Voice. It's February 2025, I'm Gavin Cleaver and today we're joined by Professor Heather Wardle to discuss the rapid expansion of the global gambling industry and its significant public health implications. Professor Wardle is a Professor of Gambling Research and Policy at the University of Glasgow and she was the Lead Commissioner on the Lancet Public Health Commission on Gambling.

Now, gambling has become an almost inescapable part of our lives, with its presence felt on the high streets, in advertisements and especially online. But how does it pose a public health concern? We're going to look into the health harms associated with gambling, the industry's global reach, and the urgent need for stronger regulatory measures.

I hope you enjoy this conversation with Professor Heather Wardle.

Professor Heather Wardle, thanks so much for joining us on the podcast today. It's really great to have you with us and gambling's been something I've been keen to talk about on the podcast for a while because it feels like it's become such a present part in all of our lives. It's almost inescapable by this point.

You'd see the places on the high street, the adverts everywhere. But I guess for some of our listeners, it might not be obvious how gambling is a public health concern. So how do those two things connect with each other? 

Heather: Yeah. The first thing to say is that gambling has had this exponential growth since obviously it's relationship with technology and it's the adoption of online gambling and it's on your phone, it's on your apps, it now reaches into countries and reaches to people that have had very little prior exposure to gambling.

And that's particularly one of our concerns. Particularly if we look at places like sub Saharan Africa or even in South America the expansion of gambling globally in those places is absolutely ferocious. And yet what we know is that gambling isn't this, it's not a risk free commodity, it's not a harm free commodity.

There is a substantial risk of harms to health that are associated with it. So people can and do become addicted to gambling. You don't have to be addicted to experience harms, you can be you can experience You know financial losses, obviously, but it also can impact on your mental health.

It can impact on your physical health. It can impact on those people who are around you, who are supporting you. So it's understanding that this is, it's not an ordinary kind of commodity. It's not the same thing as, going to the cinema or going out for dinner. It does have a substantial risk of harm to health.

Gavin: What kind of forms some of those health problems take for people who might be gambling? 

Heather: In terms of the forms, it's difficult to differentiate the kind of the mental health issues with the physical health issues because obviously they're interrelated. We know in particular that People who are experiencing very severe harms, they are they don't take care of themselves.

They don't feed themselves, they don't they don't sleep, they don't have the same kind of self care as you might wish them to have. And then that can manifest in physical health issues. And of course, there's a relationship there with the mental health harms that people experience as well.

So things like anxiety, depression and so on, these are all very highly correlated with gambling harms. 

Gavin: Does this only apply to, say, heavy gamblers? Is there like a terminology particularly there for someone who's seen to be a heavy gambler and how does then their health relationship with gambling work?

Heather: Yeah, it's a really good question because I think there's a really strong narrative that is used quite often by the industry that sort of suggests, oh, it's only a few people at the very, hard end of the spectrum who are experiencing difficulties and if we could just deal with those people, then Thing else would be fine.

Everybody else gambles and has no problems, but that's not what the evidence suggests. The evidence shows there's much more of a spectrum of harms that are experienced, and you don't have to be gambling at what we might. Call the kind of the clinical disordered level to experience those kinds of harms, you can be experiencing issues with anxiety because of your gambling without being what might be termed as a disordered gambler by the by the clinicians, you can be having the after effects of, you've spent too much money and all the stress and everything that entails, again, without necessarily being at that more disordered end of the spectrum.

And we, we know when we talk to people with lived experience of gambling, these are things that they themselves have experienced. And it's also what the evidence shows us when we look at the kind of the epidemiology of gambling. 

Gavin: You mentioned at the start of your first answer there about this sort of expansion worldwide.

I think you mentioned technology, of course, but what are some of the other key factors driving this as expansion and does it focus as you, I think you touched on as well on like low and middle income countries too. 

Heather: So the expansion's driven by a number of things it's obviously the technology facilitates it and then because you have this tech, technological provision of gambling, which essentially transcends global boundaries.

It's not as possible anymore to be able to say as a jurisdiction we are going to allow or not allow gambling when it was a physical entity. Because you could say we're just not going to build any casinos, but now that it's an online commodity, it's very easy for people to work around those things.

So for example, in our Lancet public health commission, we had commissioners from Indonesia. In, in Indonesia gambling is not allowed and yet she has really startling figures of how many people are accessing online gambling and how many people are experiencing harms from those, from from that gambling.

So you've got that kind of technological provision, which means it reaches now into places and countries that never had it before. Then you also have jurisdictions, particularly I would say in North America, which are looking to gambling because, it, it raises revenues. So it's saying we never had gambling before, but actually now that it's this online entity, we can't really restrict it, so why don't we regulate it, but primarily a lot of the motivations is actually about getting revenues from gambling through taxes for the state.

So you have multiple different motivations that are coalescing to allow this rapid expansion. 

Gavin: I see. That makes sense because. the more gambling is encouraged or permitted, by the government, the more money they actually make in the tax that they can make gambling bodies pay.

Heather: Yeah. And when we looked at so we looked at 38 different states in the USA and we actually looked at their legislation for where they were permitting mainly online sports betting for the first time. And we looked at their stated motivations and their stated motivations. Yeah. Some of it was about.

Making sure that the gambling that was provided was fair and transparent and keeping crime out of gambling. Absolutely fine. But a really strong motivation was also about bringing money into the state, promoting economic growth, promoting revenues. And some of them even then specified where that money was going to.

So looking at the where the money was going to in the States was really interesting because a lot of the money was then going into supporting and firming up public sector provision. So going into education, going into health, going into infrastructure and so on. So it then wheedles its way throughout every part of public life.

Gavin: How effective generally is the kind of, what's the relationship like I guess between government bodies and gambling companies. There's a lot of lobbying involved, a lot of back and forth. I guess to use the example of the UK, it feels for a while now, we've acknowledged that things like high street gambling is a little bit out of control, sponsorship of football teams, for example.

But a lot of the time, it feels like the main regulator of betting are the betting companies themselves, they have all those adverts that are like, know your limits and stop at the right time and things like that. But this seems to be an area where legislation is lacking.

Heather: The approach to regulation, exists on a huge spectrum. And globally it varies. So I'll talk about some typical examples, but yeah in each country, there are different shades of gray on these things. Typically your approach to regulation ought to be underpinned by the level of risk that is acknowledged to be associated with the products.

And what we have is a situation by which actually almost universally the risks associated with gambling are underestimated. And therefore, if you underestimate the level of risk. Then your regulatory responses to how you manage those risks are going to be underspecified. And we see that quite a lot when we review gambling legislation and gambling regulation worldwide.

And then what often then happens is you tend, when you think the risks are low, you tend to then say you know what, actually we could have more of a self regulatory model by which we actually trust the industry to regulate itself and regulate in the public interest. And that's hugely problematic because you need the private interests of the industry to align with the public interests of health protection.

And one of the reasons it's hugely problematic is there is an increasing evidence base that shows that a disproportionate amount of gambling profits are actually generated from those people who are harmed. So you don't have the same kind of incentive structures for the gambling industry to actually regulate in the public interest because the people that they would then actually be regulating more strongly would be the people who are most profitable to them.

And that's that's, it's a fundamental issue with how gambling typically can be approached. It's not the same in every country. Other countries are more prescriptive. And so on, but that is, is a fundamental tension around the regulatory approach that we have. 

Gavin: How do gambling companies act towards these heavy users?

At what point do they notice and stop harms? 

Heather: Oh, that's a really interesting question because in lots of countries the UK included. The approach has been that the gambling companies themselves should do behavioral profiling on people, particularly online, because it's possible because you have the data but do behavioral profiling on people who are gambling very heavily and to intervene with them when they are displaying what they call markers of harm.

And it's not quite clear so that, that's been the approach. It's not quite clear how effective that is. The industry have developed their own algorithms and they haven't necessarily been independently evaluated. But fundamentally, from a kind of prevention point of view, that is waiting to see people getting into a behaviour or a pattern of behaviours that is harmful and then intervening with them.

Obviously, we would prefer much more upstream prevention initiatives to prevent people getting into that situation in the first place. So you've got this It's, and it sounds very good on the face of things, but when you start digging under the bonnet a little bit more, you're not actually quite sure what's going on.

Again, you're putting that trust in the corporations to actually do this and do it effectively. And we've talked about, where there might be misalignment between public and private interests. And then you also see quite often. Examples of mispractice within the industry. So really recently, in fact, in the past two weeks, we've had a high court ruling in the UK where it was found that a gambling company profiled somebody who was experiencing problem gambling unlawfully and targeted, I think the high court judge said it was something like 1300 advertising messages and promotional offers to that person.

And that was ruled as unlawful use of data. We've also seen just recently, there's been a, we've also seen just recently, there's been some investigative journalism looking at how gambling companies are sharing data with Meta and Facebook without people's consent, and then they have been targeted with lots of advertising.

So again, When you look under the bonnet of these things, there are a multitude of practices, and it comes back to that question of really how aligned are the public and private motivations here. 

Gavin: You mentioned at the start of that answer the harms that gambling companies were meant to notice.

What are some of those harms? 

Heather: So the kind of behavioral markers that people will be looking for in, in the data will be around, how frequently people are gambling, how often, their patterns of how their Actually like gambling within a session. So if you can see that somebody has lost and then they're piling in more money and they're chasing essentially those kinds of less safe patterns of gambling behavior.

And there's a whole variety of these different kinds of markers. It could be also gambling very late at night as well as the way that they actually deal with their accounts. The way that they withdraw their money and they place their bets and so on. So there's a whole range of different things that these companies will profile and look at and say, actually, if you're gambling in this particular way, we think this might be a sign that actually you're, you may be experiencing harms.

And then that is supposed to trigger this kind of intervention from the gambling company. In terms of the harms that people experience, it is that kind of. All getting all consumed by gambling needing to gamble with more and more money to get the same kind of the same kind of enjoyment, chasing your losses being preoccupied about your gambling, ignoring everything else in order to gamble.

These are just some of the kind of more kind of clinical symptoms that people talk about. And then of course those symptoms have. implications and expressions in your everyday life and how you conduct yourself with your family your friends, how you're able to function as a human being in everyday life.

Gavin: We, we talked about how this brings a kind of tax base in for the government, but it must also cost the government. a certain amount to deal with the burden of gambling disorder. 

Heather: Yeah, it absolutely does. At the most extreme end of the experience of gambling harms, yeah, there is a known and recognized relationship between.

Gambling disorder and suicidality. And there are gambling related suicides. And for the first time in Great Britain the suicide prevention plan in England at least recognizes gambling as a dominant factor without which suicide would not have occurred. Now there is quite clearly a societal cost associated just with that aspect of the harms that are associated with gambling.

And then there are other societal costs. There are costs around relationship breakdowns. Quite often people who are experiencing gambling harms, they will be in conflict, they will have disruption. To their relationships, there will be the mental health costs of actually treating people. The health costs of treating people and then also the associated mental, wider mental and physical health costs.

And that's on top of the actual financial and fiscal burden that that can be accrued. The difficulty is, it's much more difficult to put a fiscal cost estimate on each one of these things. And people have attempted it and you have to make a whole number of assumptions and you can try to work that out, but it's not as clear cut as the industry then coming and saying, Oh we contribute so much in tax dollars, we contribute so much in in revenue from gaining duty.

And so you have this asymmetry of insight whereby the industry are able to actually quite clearly articulate what their actual contribution is. And we absolutely know there are this wide range of social costs, but it's much more difficult to articulate that in monetary value. 

Gavin: That's really interesting.

And during all of this, how does the gambling industry portray itself in public? 

Heather: So the gambling industry, and I think it's probably important to say that when we talk about the gambling industry here, these are a number of different industries across different products. We're ranging from lotteries right through to your kind of online casinos.

That said, probably aside from lotteries, a lot of the main gambling corporations now, they may have originally been focusing on sports betting, but they will now have online casinos, slots, online bingo. They will have multiple products across their portfolios. Their tendency is to portray gambling as harmless, as fun, as recreation, as exciting, and to really minimize the scope of problems that are associated with the products they provide.

So you will quite often hear an industry representative say something like, less than 1 percent of the population experience. Harms from gambling, everybody else finds gambling fun and exciting and entertaining. And that's a quite serious misrepresentation of the evidence and the data. Because actually, it's always quite interesting to me when you look at this, actually when you look at the data.

You might think that everybody is gambling, but actually, not everybody gambles, and in many countries it's less than half of people in the population are gambling. If you have this kind of misrepresentation of saying, oh it's only 1 percent and everybody else is fine actually, half of that other group aren't actually even doing this thing.

So when you start drilling down into what do harms look like amongst the people who are actually engaging and engaging in a regular way with these products, all of a sudden you then start to see figures like maybe 15 or 20 percent of the people who play online slots or casinos are experiencing gambling harms.

It flips the narrative all of a sudden, yes, you, it's still not the majority, but you have a substantial proportion of those who are playing engaging in these products, experiencing harms. And that is, that should be taken into account when you're thinking about what is the risk associated with these products?

How high or low risk are they? They are actually much higher risk than population prevalence estimates would suggest. Okay. 

Gavin: Yeah, one of the reasons I wanted to talk about it on the podcast is because it feels all so pervasive, but for instance, I'm a huge sports fan, and I've never placed a bet in my entire life, and I feel like this point, like I'm going a little bit mad, because it feels like the way it's portrayed is that I'm the only person left watching sports that hasn't placed a bet by this point, but obviously there must be many more people that haven't placed a bet, but it's so pervasive within the sporting world by this point.

Heather: Yeah, and that's what the industry want you to think. They want to think, they want you to think that you're the abnormal one, that everybody else is doing this. It's completely normal and this is what, if you're a sports fan, that's what you should be doing. And actually when you look at the data, you're right, yours is the normative pattern of behavior.

Most people don't actually engage in sports betting. So I remember rightly the latest data from the gambling survey for Great Britain was something around 15 to 20 percent of people had bet on sports in the last four weeks. So actually majority of people haven't. And that again is really insightful into, how the gambling industry operates, because actually if you think about how many different operators there are, not that many people in the population doing this.

An even smaller proportion of doing this who are going to be the kinds of people that the operators make money off, therefore, yeah they've got really intense competition for a small proportion of profitable people. Which again, then you get into all these, you get into a really quite aggressive advertising and marketing scenarios to fight for your piece of the pie.

Gavin: How do we break this cycle then? How can we kind of persuade governments to better? Regulate gambling. 

Heather: It's a really good question. I think, we start with the recognition that, yeah, actually government's role is to protect the interest in the health of their citizens and leading on from that, they need to really understand what the risks are associated with these products.

And once they have understood the profile of the risks and understood that those risks have been substantially underestimated, then actually implement effective. Regulation that is proportionate to those risks in more plain, simple language that's things like actually it will be having greater restrictions on the supply of certain types of products, putting greater protections around these products for people.

For example, how saying how much you're, you think it's okay for someone to lose. On these products in a given month, really restricting the advertising and the marketing techniques that people are using that create this air of like normalization, essentially it's those kind of activities that we need to have much, a much stronger handle on.

Gavin: How much of an outlier is the UK in terms of gambling advertising? Obviously, I don't have a huge amount of experience of how it's portrayed in other countries, but it seems especially again, when you watch sports over here, every single ad break is two or three different advertising messages for gambling companies.

Heather: So the UK is a really interesting example because we've just had a government white paper. That was released and they talked about the things they wanted to do to get greater protect, have greater protections from harms from gambling and advertising and sponsorship was something that. They mainly decided to leave in the hands of the gambling industry.

For example, instead of actually saying, like Spain, for example, have done, you can't sponsor football teams, they've implemented a voluntary front of shirt ban that will be implemented from 2026. But we've seen already that the front of shirt sponsorship deal will be banned, but then they haven't banned the back of the shirt or the sleeve of the shirt.

Or having betting partners. So those things will still exist. And in terms of its its approach, there are numerous countries across Europe who are taking much stronger approaches on either prohibiting or having much, much stronger regulation on how advertising and marketing is presented.

So I do think the UK is. Compared to those countries, it is behind the curve, and those countries include, Spain, Italy, Belgium, Lithuania, and so on. 

Gavin: But the US is going in the other direction, right? I remember when I lived there, I used to live in Texas. I remember when I lived there, placing a bet was illegal, essentially, especially on sports.

But now, it seems to be wheedling its way back into the conversation with the kind of wave of legalizations around different states. 

Heather: Yeah. The U. S. is a really interesting case in point because I say, I think where the USA is now is where Britain was back in 2005 when we had the first wave of liberalization.

And if you look at what's happened in Britain, so there was that kind of first wave of liberalization where advertising and sponsorship was allowed, also coincided with the growth of online provision. It took about 10 years before there was any kind of real media or political interest in this as saying, actually, are we sure this is really what we meant, what we wanted.

And a lot of that was actually driven by people with themselves with lived experience coming together to actually say, this is what gambling has done to me and I, we need greater protections and. Particularly people who've experienced gambling related suicides are quite often the bereaved relatives of people who've taken their own lives because of gambling.

And that started to shift the dial and it is now a topic of debate. It, it may not still be satisfactorily determined, but it is a conversation that is happening. And I think the U. S. is at the start of that process. They will probably have, hopefully it might not be the whole 20 years that it's taken in the U.

K., and it might be a little bit more accelerated, but it will be that process of something something different has happened. We now see how this is manifest. We now have a period of reflection thinking, actually, was this really what we wanted? And do we need to revisit and tighten up our regulatory approaches?

Gavin: And what does the international conversation on gambling look like? Because obviously with the kind of digitalisation, you've got the kind of ability to cross borders with placing bets. I guess that becomes a sort of difficult grey area for legislation. 

Heather: So one of the key questions, and it is an important question, is that issue of, you can't, it's very difficult nowadays just to prohibit this thing, we started off talking about this.

And so you have unlicensed or gray gray market or even black market provision that is fairly easily accessed. So reg, regulating and trying to manage that. Does does appear to be the most sound way forward. But what then happens is that when you try to impose perhaps more stricter forms of regulation on the gambling market, the industry will say you can't do that because everyone will just move to the black market and then you'll lose all this revenue in the black markets, all and very unsafe.

And it's that arguments presented in a very deterministic fashion that if you do this, then this will happen. But it's again, it misses quite a lot of the nuances and the subtlety of how people actually gamble how engaged people are with gambling, how much it actually forms a really deep part of their lives.

And actually for Quite a lot of people who gamble, there is evidence and work that I've done that their kind of viewpoint on this is a little bit more I could take it or leave it. So actually, if there were a bit more regulatory restrictions and tensions on this one, I might not be so bothered and two, if it means I don't gamble so be it.

Now that's incredibly worrying to the gambling industry which is why they invoke this kind of fear of the black markers. But there are, there, there is also truth in this. There are people who are really deeply engaged in gambling and they will use unlicensed provision and look for alternatives.

They will likely be the people who are most profitable to the industry, which is why they're concerned about them. But this narrative of whole scale shift isn't really reflective of what the patterns of behavior change would be. There would be a small proportion who may seek out alternative provision, but it wouldn't be a wholesale by any means or stretch of the imagination.

Gavin: Now you were the lead commissioner on the Lancet Public Health's commission on gambling, which came out towards the end of last year. What sort of effect has that commission had so far? 

Heather: The effect's been really exciting, actually, because we've, I feel like we've started to have a bit more of a global conversation around gambling and its impacts in the public health dimensions.

So we've been speaking with people in like the Argentine parliament, for example, who are, they, they are targeted for growth. The whole of South America has been targeted for growth from the gambling industry and they have concerns about that. And they're starting to think through what that might mean.

Again, we've had conversations with people in Brazil, across North America. And so on. So it's been it's been really useful to actually have a set of recommendations that we can talk to people about and then go off. It's not just me. It was, we had a group of over 20 amazing commissioners who've then all been going off and speaking to their national governments and their policymakers and their wider networks about this.

I already mentioned my colleague in Indonesia, she's been doing fantastic work out there starting the conversation. So it's early days, we only published in October, but so far there has been, there's been a lot of international interest in this and what we're saying and people appreciating it's being raised up the agenda essentially.

Gavin: And how do you hope to see this conversation develop in the following years? 

Heather: Oh, in an ideal world where these conversations would get to. Would be more formalized international and intergovernmental action on gambling. Particularly we highlight and target the WHO as a key partner in that as the organization who actually has the ability to be able to bring thought leadership and action to this space.

Of course. We also know that the WHO has a multitude of priorities and getting your gambling will have to fight for space and fight for attention. We are hopeful that some action could be taken and that we would see organizations like the WHO or other UN entities start to incorporate gambling into their portfolio of work.

And quite frankly, It would be amazing the next time, for example, one of these big intergovernmental organizations publish a strategy on suicide prevention. Gambling was actually recognized within that, or on mental health, gambling was recognized within that. At the minute, gambling's not even mentioned in any of these policy documents.

And we really think incorporating gambling and taking a more multi sectoral approach will be really beneficial. 

Gavin: That's really interesting. It's been a really fascinating chat. It's answered a lot of questions that I've had myself about about gambling and the health harm. So Professor Heather Wardle, thank you so much for joining me on the podcast.

Thanks so much for listening to this episode of The Lancet Voice. If you'd like to find out more about The Lancet Group's podcasts, you can go to thelancet. com slash multimedia, where you'll also find all of our excellent infographics and videos. If you're not subscribed to The Lancet Voice, then you can find it wherever you usually get your podcasts, and we hope to see you again next time.

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