Abstract
The focus on the determinants of health and inequalities in recent years has brought into focus the commercial basis of many contemporary challenges. Increasingly this involves a range of addictive behaviours. Historically, the major concerns were largely in relation to alcohol, tobacco and a range of other substances on a spectrum from prescription medicines through the cannabis family and hallucinogenic substances to hard core narcotics including heroin and cocaine. While society has struggled and vacillated in its approach to this list, the recent tendency has been to swap a criminal approach for a medical one based on education, regulation and harm reduction. 1
In democratic countries, the tension between individual liberty and state intervention has often been contested with public health being seen as a Trojan horse for the nanny state and in opposition to legitimate commercial interests. The emerging settlement has included a recognition that in protecting populations from the potential harms of addiction it is desirable to restrict the promotion of these agents by the normal commercial vectors of advertising and sponsorship in their manifest forms. However, this rational approach has yet to make much headway in the face of the threat posed by more contemporary problems including epidemic obesity, the undesirable exposure of adolescents to adult online content and the promotion of gambling through the full range of tools available from social and mainstream media to extensive sports sponsorship at both professional and grassroots levels. 2
While the emergence of Harm Reduction as a pragmatic response to the concern over widespread drug use since the 1960 s has sometimes seemed to be the better of two evils, its uncritical adoption may bring with it untoward consequences as now seems to be the case with the extensive adoption of vaping seductively flavoured electronic nicotine devices by teenagers and an uncritical acceptance by mainstream bodies such as ASH and GambleAware of industry claims of the benign nature of their activities. In the case of e-cigarettes, previously respectable organisations were taken in by the suggestion that they were 95% less harmful than tobacco, a fanciful number with no possible evidence base at such an early stage in the marketing of a new product. 3
When it comes to gambling, there has been exponential growth in the size of the industry in recent years driven by the aggressive use of modern media preying on human weakness and the hopes for instant wealth, a baseline having been set perhaps by the ubiquitous presence of national lottery schemes. In the UK, the front runner is the multibillionaire founder and owner of the gambling firm Bet365, Denise Coates, who was reported to have paid herself £265m in 2017. 4 A clue is contained in the very name of the company, with online gambling now possible 24 h a day, every day of the year.
The price for this extreme manifestation of an uncritical acceptance of commercial exploitation of human frailty can be measured most starkly in the number of annual suicides associated with gambling debt, currently running at over 400 each year in the UK. 5 This is the outcome of an expenditure of £1.5b spent each year on gambling advertising, with 86% of betting profit coming from 5% of customers; it is estimated that 55,000 children are addicted to gambling.
Despite increasingly vocal calls for a ban on gambling-related advertising, not least by bereaved families, the government continues to pull its punches, with MPs enjoying links with gaming companies and GambleAware, one of the organisations we might look to for leadership, appearing to be a victim of the playbook pioneered by other addiction-dependent industries.6,7 As a beneficiary to the tune of £19m in donations during the 12 months ending 31 March 2021, largely from the top four gambling companies (Entain, William Hill, Flutter and Bet365), rather than campaigning for an end to the advertising and promotion of gambling, the focus of GambleAware is primarily on harm reduction and treatment. There is no such thing as a free meal, and the comfortable symbiotic relationship has recently been recognised by the award of honours at board level.8–11
The United Kingdom is not alone in experiencing the pandemic of gambling with its related harms. Australia too has experienced this recent phenomenon and it has been suggested from a Swedish study that there has been a 15-fold increase in suicides among people in the 20–74-year age group experiencing gambling issues. 12
The World Health Organization has so far not addressed the issue of gambling alongside other addictive behaviours. Part of the problem appears to be a framing based on biology and human weakness rather than on social, economic and political considerations. Each has a part to play. What is needed is a reframing from one primarily of individual weaknesses requiring piecemeal, downstream, individual medical interventions, to one of public health problems that are part of the collective human condition requiring societal responses. In the 21st century, is it too much to ask?