What is known about population level programs designed to address gambling-related harm: rapid review of the evidence

Abstract

Background

Gambling and gambling-related harm attract significant researcher and policy attention. The liberalisation of gambling in most western countries is strongly associated with a marked rise in gambling activity and increases in gambling-related harm experienced at the population level. Programs to address gambling-related harm have traditionally focused on individuals who demonstrate problematic gambling behaviour, despite clear evidence of the effectiveness of a public health approach to high-risk activities like gambling. Little is known about the availability or efficacy of programs to address gambling-related harm at a population level.

Methods

The Victorian Responsible Gambling Foundation commissioned a rapid evidence review of the available evidence on programs designed to reduce gambling-related harm at a population level. The review was conducted using a public health and harm reduction lens. MEDLINE, ProQuest Central and PsychInfo databases were searched systematically. Included studies were published in English between 2017 – 2023 from all countries with gambling policy contexts and public health systems comparable to Australia’s; included primary data; and focused on primary and/or secondary prevention of gambling-related harm or problems.

Results

One hundred and sixty-seven articles were eligible for inclusion. Themes identified in the literature included: risk and protective factors; primary prevention; secondary prevention; tertiary prevention; target population group; and public health approach. The evidence review revealed a gap in empirical evidence around effective interventions to reduce gambling-related harm at the population level, particularly from a public health perspective.

Conclusions

Addressing gambling-related harm requires a nuanced, multi-layered approach that acknowledges the complex social, environmental, and commercial nature of gambling and associated harms. Moreover, evidence demonstrates community programs to reduce gambling-related harm are more successful in reducing harm when based on sound theory of co-design and address the social aspects that contribute to harm.

Background

Gambling is entrenched leisure activity in Australian society, sanctioned and regulated by government. Approximately 35% of all Australian adults spent money in a ‘typical month’ on one or more gambling activities [1]. The estimated per capita personal spend is $133 for a typical month [2]. In the Australian state of Victoria, gambling activity associated with poker machines was estimated to be $2.7 billion for 2018–2019 [1,2], with the estimated national spend at $12.7 billion for the same period. This spend on gambling activities means Australia has been described as the gambling capital of the world [3]. The negative impact, or harms, associated with gambling (i.e. gambling-related harm) are complex but well understood [4]. Gambling-related harm extends beyond the person who gambles to ‘affected others’ and the community. Harms are seen across financial, emotional, health, cultural, workplace and criminal domains with increasing lasting impact from a temporal perspective [4].

Attempts to understand and address gambling-related harm have mainly focused on individuals who gamble and their problematic behaviours and/or addiction issues. Language used to describe harm experienced as a result of gambling has varied over time and demonstrates a shifting perspective in terms of where harm originates and where responsibility may lie. The dominant discourse has been around ‘responsible gambling’ and ‘problem gamblers’, which propagates the notion of personal responsibility and problematic or dangerous personal characteristics and behaviours [5]. Critics of the responsible gambling view of gambling harm argue that this individualistic approach fails to appreciate the broad and complex nature of gambling-related harm beyond the individual who gambles [6]. Calls to adopt a public health approach, informed by principles of harm reduction, to gambling and gambling-related harm have resounded for many years [6,7]. Harm reduction, or harm minimisation, is generally associated with reducing adverse impacts from addiction practices where abstinence is not a desired outcome but adverse health outcomes are reduced as much as practicable [8]. Crucially, language has shifted from an individual focus—the ‘problem gambler’ demonstrating ‘problem gambling’ who should engage in ‘responsible gambling’—to a broader, more nuanced view of where and how gambling-related harm is experienced [4]. Specifically, Langham et al. (2016) take a social view of gambling-related harm to define it as:

Any initial or exacerbated adverse consequences due to an engagement with gambling that leads to a decrement to the health or wellbeing of an individual, family unit, community or population. [4]

A public health approach is helpful to design and deliver programs to address gambling-related harm when a social view of gambling is adopted, [6]. Programs designed using a public health approach can focus on primary, secondary or tertiary prevention, or incorporate aspects of each level of prevention [9]. Public health approaches include preventing harm, early intervention to minimise likelihood of harm, and treating harm [9].

Legislation mandates in some Australian states requires an identified proportion of all gambling revenue is dedicated to treating and preventing gambling-related harm [10,11], alongside establishing quasi-autonomous non-government agencies (QANGOs) responsible for reducing gambling-related harm [12]. This rapid review was undertaken to inform the creation of a programming framework for the Victorian Responsible Gambling Foundation that has operated for over 10 years, in Victoria, Australia to reduce the social, health and economic costs of gambling-related harm via a public health approach.

This rapid review focused on identifying available evidence about effective public health responses to gambling-related harm by examining international, English language, peer reviewed literature on:

• What is known about programs designed to address gambling-related harm?

• What evidence is there of the impact of gambling-related harm prevention programs on priority population groups?

• What is known about the risk and protective factors for gambling-related harm, particularly in priority population groups?

The key purpose of this review was to inform what action could be taken at the population health level.

Methods

Search strategy

A rapid evidence review is an assessment of available evidence related to a current policy or practice issue [13,14]. It is a form of knowledge synthesis in which components of a systematic review are simplified to expedite the process. As such, we adopted the procedure as described by Haby et al. [14]. A mnemonic was used to help construct the search strategy (PICO: Population; phenomenon/Intervention of interest; Context; and Outcome) [15]. All reporting was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [16]. Given the public health focus of this review, we systematically searched three key databases (MEDLINE, ProQuest and PsycInfo). We also conducted a grey literature search, which will not be reported.

We used a combination of terms for searching databases to elicit responses to the research questions, using the following key word combinations:

(gambling OR responsible gambling OR problem gambling) AND (harm reduction OR harm minimisation OR prevention) AND (access AND exposure AND community AND stigma AND uptake AND capability).

Searches were limited to literature published between January 2017 to November 2023 from countries with gambling policy contexts and public health systems similar to Australia, like the UK, USA, Canada, and New Zealand. These countries all have a hybrid welfare and market model of health care delivery and/or a similar proportion of GDP spend on public health [17].The decision to limit the search timeframe was a pragmatic one. Rapid evidence reviews often require tighter windows for age of evidence, and an existing systematic review addressing similar research questions conducted in 2017 further influenced our selection of search timeframe.

Inclusion and exclusion criteria

Studies were considered for inclusion if they: referred to prevention programs that primarily focused on gambling-related harm or problems; were focused on primary, secondary and/or tertiary prevention of gambling-related harm; and/or included primary data.

Studies were excluded if they were: studies on clinical interventions for individuals with a diagnosis of pathological gambling, as per Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) [18]; or described non-applied research.

For this review, we adopted Langham’s (2016) definition of gambling-related harm described above. All articles that made specific reference to programs designed to address gambling-related harm were considered for inclusion. Given the paucity of available evidence, we did not assess the quality of any articles to avoid excluding data based on research design.

Data extraction

The research team discussed the literature identified and agreed upon common themes present across the literature that were relevant to the research questions. Peer reviewed literature was loaded into the screening and data extraction software Covidence to help ensure rigor and reproducibility [19]. Each included citation was independently screened by a member of the research team (SC and VW), with conflicts and queries assessed by a third member of the research team (DR).

Results

Searches returned 1559 articles, of which 696 were duplicates. Following title and abstract screening, 319 articles were assessed at full-text stage, with 152 excluded. Excluded articles were either: outside the timeline for capture (n = 74); not within the study scope (n = 57); had limited relevant information (n = 11); editorials (n = 7); included the wrong study outcome measures (n = 2); or a correction (n = 1). Hence, a total of 166 articles met the criteria for inclusion and were included for data extraction. A PRISMA diagram relating to this process is shown in Fig. 1.

Fig. 1

PRISMA diagram of included citations

One hundred and sixty six articles were included in the review: 93 quantitative studies; 28 qualitative studies; 30 review studies (including 12 systematic reviews); 5 mixed methods studies; 8 randomised controlled trials; 1 process/program evaluations; and 1 Cochrane systematic review (see Table 1). The studies were from 20 national jurisdictions: Australia (n = 28); USA (n = 24); Canada (n = 18); Spain (n = 10); Germany (n = 7); Italy (n = 7); United Kingdom (n = 7); France (n = 5); Croatia (n = 4); Finland (n = 4); Sweden (n = 3); Norway (n = 3); New Zealand (n = 3); Switzerland (n = 2); Korea (n = 2); Poland (n = 2); China (n = 2); Portugal (n = 1); Singapore (n = 1) Cyprus (n = 1); international collaborations (n = 3). Literature reviews were not assigned a national jurisdiction.

Table 1 Data table for included citations

Results were recorded and arranged according to the research questions and the project focus on a public health perspective with relevant themes from the literature: risk and protective factors; secondary prevention/harm reduction; primary prevention/early intervention; target population group; public health approach; and tertiary prevention/treatment.

Q1. What is known about programs designed to address gambling-related harm?

Evidence related to gambling-related harm prevention can broadly be categorised according to levels of prevention: primary, secondary, and tertiary prevention. For readability, findings will be presented accordingly.

Primary prevention

In large part, evidence around primary prevention or early intervention for gambling-related harm programs were school or university-based and tended to be educative programs targeting cognitive distortions or misconceptions around gambling risk [20,21,22,23,24,25,26,27,28,29,30,31,32,33]. Several literature reviews, some systematic, referred to successful primary prevention programs in schools. They found that programs that were multifaceted and addressed context as well as individual attitudes and beliefs were more effective at reducing at-risk or problematic factors, like misperceptions of gambling and illusions of control, in the longer term [22,34,35]. Grande-Gosende et al., (2019) conducted a systematic review of evidence related to programs designed for college/university students and found that programs that incorporated Personalised Normative Feedback were the most effective in terms of reducing at-risk or problem gambling among young men.

Several included studies provided primary data related to program outcomes and effectiveness [29,30,31,32,36]. Donati et al., (2018) investigated gambling-related cognitive distortions (or mindware distortions, where mindware is the rules, procedures and strategies derived from past learning used to solve problems [37]) confirming effectiveness of tailored interventions to address them. Recommendations suggested that prevention strategies address mindware problems as they can be considered predictors of gambling-related cognitive distortions. St-Pierre et al., (2017) examined the impact of targeting Negative Anticipatory Emotions and key Theory of Planned Behaviour (TPB [38]) constructs in modification of gambling beliefs, intentions and behaviours in an adolescent gambling tool—the Clean Break video [32]. Results indicated a small but statistically significant increase in positive gambling attitudes and positive peer and family subjective norms at post-intervention and follow up, where positive is indicative of anti-gambling.

In terms of causal pathways, many of the included studies examined relationships between sociodemographic factors of individuals and either risk of developing or presence of problem gambling. However, Dussault et al., (2019) examined current poker playing adolescents to identify groups according to sociodemographic and gambling-related characteristics [33]. Findings from that study indicated that adolescents who gamble were more likely to respond to interventions designed to address ‘adult’ gambling problems as both groups of gamblers shared sociodemographic and gambling-related characteristics. Interestingly, Dussault et al. (2019), also found that adolescents who played simulated poker did not exhibit or were not at risk of developing problem gambling.

Primary prevention programs were focused on raising awareness of the potential harm of gambling, mostly to young people. There was a lack of evidence of effective education programs at a whole of community level.

Secondary prevention

In general, evidence around secondary prevention programs targeted individuals already experiencing gambling-related harm and tended to refer to ‘responsible gambling’ strategies [39,40,41,42,43,44,45,46,47,48,49]. Ladouceur et al., (2017) conducted a systematic review to identify empirically grounded responsible gambling studies to inform evidence-based, effective responsible gambling programs. Little empirical evidence was available from the 105 included citations in the Ladouceur review on which to develop intervention frameworks, and no data beyond 12 months was provided [50,51,52]. However, five responsible gambling strategies and the relative effectiveness of each were discussed, and outlined as follows [53]. Self-exclusion, where individuals participate in a program to be banned from specific gambling venues [54], was poorly adopted but more successful in the longer term if combined with individualised follow-up. Indicators of responsible gambling behaviour, where the individual exercises self-restraint, were difficult to track due to lack of access to universal data. However, gambling frequency, defined as expenditure and duration of gambling, was strongly linked to likelihood of problem gambling. Monetary limit setting — establishing a maximum spend either per bet or for each gambling session — was shown to be more effective than time limiting strategies, with some variability when limit setting is self-determined. Venue training programs were shown to be minimally effective as staff were poor at recognising patrons at-risk of gambling-related harm, with obvious disparities in self-reported Problem Gambling Severity Index (PGSI) scores and staff estimates. Staff were also unlikely to discuss issues of problem gambling with patrons due to personal discomfort. Secondary prevention was targeted at directly addressing the individual’s behaviour around gambling.

Other studies focused on the impacts of personalised feedback [51,52,55,56] and/or personal contact between counsellors and people who gamble [57,58,59,60,61,62]. Jonas et al., (2020) found that personal contact with counsellors in conjunction with other responsible gambling type interventions had the greatest impact on longterm reduction in problem gambling scores. In terms of impacts of personalised feedback for people who gambled, the most effective interventions were those that provided non-judgemental messaging based on gambling facts and amounts spent [55,63,64,65,66]. The effectiveness of computerised interventions to reduce gambling harm have been examined [67,68,69,70]. Findings indicated that ICT based interventions had widespread potential for harm reduction; however, those interventions that incorporated personalised feedback were the most effective.

Two included studies examined evidence of a public health approach to gambling harm, identifying a relative paucity of empirical evidence [71,72]. McMahon et al., (2019) conducted an umbrella review of systematic evidence around prevention and harm reduction and how these varied across sociodemographic groups. Findings indicate the majority of programs were focused on individual harm reduction, and the varying degree of impact that has on outcomes. Evidence on impacts of supply reduction was limited, with the authors identifying the urgent need for adequately focused research on harm reduction in relation to gambling. Peterson et al., (2021) also identified the paucity of empirical data around effective gambling harm reduction, examined other harm reduction fields like blood borne viruses (BBV) and smoking and outlined protective behaviour strategies (PBS) that could effectively translate to gambling harm [71]. Peterson, et al., (2021) argue that PBS effectively reduced negative consequences associated with gambling behaviours but outlined the pressing need for gambling specific evidence.

Tertiary prevention

Research on psychological interventions designed to address pathological or problem gambling is abundant. A Cochrane Review published in 2012 detailed successful therapies [73]. While outside this review timeframe, a wealth of psychologically focused research has been published since 2012, with an ongoing interest in the individual and problem gambling [29,30,31,56,74,75,76]. Research tended to explore aspects of the individual that either predisposed them to problem gambling or identified various behavioural aspects that could be measured, targeted, and adjusted such that problem gambling was avoided or reduced. Problem gambling in this context is behaviour 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 [77]. Dowling et al. (2021) discussed the benefits of examining the relationship between positive outcomes expectancies (the expectation that one stands to gain from gambling) and gambling behaviour finding no reciprocal relationship between expectancies and gambling behaviour. A possible moderating effect of positive emotional states and the importance of social supports as a moderator of monetary expectancies was demonstrated [76].

There was limited longitudinal data beyond 12 months to assess effectiveness of interventions on lasting behaviour change. Only one included study [78] provided follow up data after eight years in relation to differences between voluntary excluded gamblers compared to forced excluded gamblers with all excluded gamblers either stopping all gambling (20.5%) or reducing their gambling (66.5%) at eight years. However, this was not consistent across all gambling venue types with no difference in gambling behaviours seen in those who gambled in gambling halls (an area within a premise where games of chance are organised and conducted [79]).

In keeping with the recent shift in the gambling discourse away from problem gambling and pathologisation of individuals who gamble, Blank et al., (2021) conducted a systematic mapping review to capture evidence from interventions designed to reduce gambling-related harm [80]. Included reviews were divided into those reporting universal/primary prevention interventions and those evaluating interventions for individuals at high-risk of harm. There was support for primary prevention through supply reduction that included screen pop-up messaging, despite a general lack of empirical evidence in the literature. Therapeutic interventions were shown to be effective in the short-term with minimal to no long-term data. Blank et al. (2021), pointed out the limitations of programs referring to problem gambling or problem gamblers in addressing gambling-related harm at a societal or population level. They argued that focusing on ‘problem-gamblers’ fails to address underlying causes of harmful behaviours and the influence of gambling policy and supply. They argued for the pressing need for evidence to support specific types of interventions for gambling-related harm reduction.

While programs designed to address problem gambling exist at the primary, secondary and tertiary levels of prevention, they are focused on individual behaviour and in specific cohorts.

Q2. What evidence is there of impact of gambling-related harm prevention programs on priority population groups?

Priority population groups are those groups that face inequitable burden of high risk activity (gambling-related harm) when compared to the general population, such as Indigenous peoples, older people, and people who live outside the metropolitan area [81]. We based our selection of priority groups on current national, non-gambling specific, priority groups as outlined by the Australian Institute for Health and Welfare (AIHW) [81]. There is limited evidence on the impact of gambling-related harm prevention programs on priority population groups, with only evidence related to Indigenous peoples, older people, young people, LGBTIQA + and migrants captured in this review.

Indigenous peoples

Two articles referred to harm reduction programs specific to Indigenous peoples [82,83]. Whiteside et al., (2020) conducted a systematic review of interventions in Indigenous gambling identifying four articles, only one of which provided (indeterminant) outcomes data. This is supported by Saunders et al., (2021) who also identified a dearth of empirical evidence to inform the design of policy and interventions for Indigenous populations.

Older People

Evidence related to programs specifically designed for older people (recorded as aged 65 years and older) was limited in the literature, but still instructive [84,85,86]. Skinner et al., (2018) operationalise existing best-practice frameworks [85] to produce guidelines for use by practitioners, patients, families, policy makers, and concerned others. These guidelines focus on five key areas including person-centred and family-focused care, screening and assessment, secondary prevention and early intervention, tertiary prevention and specialised treatment, and ongoing support and recovery services.

Young people

Research on programs designed to address gambling-related harm in young people were predominantly focused on primary prevention / early intervention and were schools-based programs, as described earlier. McArthur et al., (2018) conducted a systematic review of interventions designed for primary and secondary prevention for individuals up to 18 years across multiple risky behaviours, including gambling that were conducted at the individual, family or school level [87]. Forty percent of included studies were conducted in school settings with findings indicating that schools-based programs were the most effective for addressing key risky behaviours with no clear suggestion as to why these programs were more effective. Evidence was minimal as to the effectiveness of interventions targeting families when compared to the effectiveness of broader focused programs [88,89].

Migrants

While the experience of migration may impact people’s gambling behaviour, we acknowledge that other aspects of cultural identity beyond migration may also be a factor. In this context, migrants are understood to be first-generation migrants who have recently arrived in the country in which the study took place [90]. Drawing from Wardle et al., (2015), we acknowledge the distinction between migrant status and ethnicity, and the obvious overlap between ethnicity and ethnic cultures. There was a general paucity of evidence specific to migrants; however, one included study provided primary data related to a dedicated public health intervention specifically targeting problem gambling across an entire city [91]. Elbers et al., (2020) examined the impact of a collaborative approach across statutory and volunteer services to reduce problem gambling in one UK city. Within that study, migrant groups were identified as being of particular interest due to the presence of the ‘harm paradox’ [92]. Drawing from work in alcohol and other drugs, Wardle et al. (2019) explain that the harm paradox is seen in certain population groups with particular characteristics (lower socioeconomic position, for example) where those population groups are less likely to gamble but if they do gamble, they are more likely to experience harm.

Q3. What is known about the risk and protective factors for gambling-related harm, particularly in priority population groups?

Overview

We use the definition of risk and protective factors in line with Billi et al., (2014) where “risk factors are attributes associated with the development of gambling problems, and protective factors are attributes that provide resilience or protection from the development of gambling problems”. The evidence related to risk and protective factors for gambling-related harm largely spoke to risk factors.

Risk and protective factors for gambling-related harm are similar to other public health issues like alcohol, tobacco, physical activity, obesity, and blood borne viruses. Evidence outlines strong associations between sociodemographic characteristics and increasing gambling severity and levels of gambling-related harm [94,95,96,97,98,99,100,101,102,103,104,105]. Specific sociodemographic factors were identified across numerous studies and include a mix of risk and protective factors such as increased educational attainment [106,107,108,109,110,111], relative deprivation [112,113,114], parental engagement and role modelling [115,116,117,118,119,120,121,122,123,124], peer group behaviour [125], and location of residence relative to numbers of gambling venues [126,127]. Coincidental substance use and/or abuse was also identified as a strong risk factor for gambling, both in terms of frequency and severity (amount of money lost per event) [128,129,130,131,132,133,134], along with increased diversity of gambling product use and frequency [135,136,137,138,139]. The normalisation of gambling and/or sports betting was also explicitly described as a risk factor in gambling activities in pre-teens. Nyemcsok et al. (2021) argued that increased awareness of marketing influence around sports betting was a key factor in predicting reduced gambling activities of young people. Roderique-Davies et al., (2020) also argued that exposure to gambling advertising in the absence of awareness of marketing influence, is a strong risk factor for gambling urge.

Activities like gaming (the use of video games), and particularly purchasing loot boxes (purchasable video game content with randomised rewards) in computer games, has recently been identified as a significant risk factor for developing problematic gambling [142]. These are sometimes described as “gateway activities”. Drummond et al., (2020) found in their international survey that individuals who regularly purchased loot boxes while gaming exhibited symptoms of problem gambling and changes in mood.

The psychological literature provides a wealth of information about various individual characteristics that may be associated with developing problematic gambling [75,76,143,144,145,146,147,148,149,150,151,152,153,154,155,156], and how these may be experienced across various life stages and related to other risky behaviours [98,157,158,159,160,161,162,163]. The interaction of comorbid mental health issues has been clearly associated with gambling-related harm [164,165], with a strong relationship between depression, anxiety and at-risk or problem gambling. Again, while much of this research demonstrates correlation, it is impossible to definitively outline causation given the socially constructed and complex nature of gambling and gambling-related harm [166]. The interaction between traumatic brain injury (TBI) and problem gambling (PG) was also examined in two separate studies by Turner et al., (2020 & 2019), finding a link between TBI and PG but no evidence of a causal relationship [167,168].

While much of the included literature described risk factors, Dowling et al., (2021) examined the protective nature of positive mental health characteristics like general coping, emotional support, spirituality, interpersonal skills and global affect. They found that emotional support in conjunction with a strong sense of self were protective against developing problem gambling [75]. Rash and McGrath (2017), who also examined potential protective factors for young adult, non-gamblers, identified religiosity and non-alcohol consumption as potential protective factors for gambling abstinence [169].

There is increasing evidence about the relationship between media campaigns and intentions to gamble across various demographic groups [170,171]. Bouguettaya et al., (2020) conducted a meta-review to establish the relationship between gambling advertising and gambling-related attitudes, intentions, and behaviours. Findings from the 24 included studies demonstrated a strong positive relationship between exposure to gambling-related advertising and intentions to gamble. Once again, the lack of longitudinal behavioural data was cited as a limitation to the strength of the finding and a key future research area.

Priority populations

Like evidence that refers to targeted interventions, this review captured limited empirical evidence of risk and protective factors for priority populations within the identified search period. Available evidence was specific to Indigenous peoples [172,173], older people, migrants, women [173], and the LGBTIQA + community.

Indigenous peoples

Williams et al., (2022), in an examination of Canadian population-wide health data, identified several predictive indicators of Indigenous problem gambling. Specifically, use of electronic gambling machines (EGMs), the presence of gambling fallacy beliefs, having a mental or substance use disorder, sports betting and being male were likely to contribute to problem gambling in Canadian Indigenous peoples. Sharman et al., (2019) conducted a systematic review of psychosocial risk factors in disordered gambling across identified vulnerable groups, where disordered gambling is an umbrella term for gambling related harm. For Indigenous peoples, a history of discrimination and dispossession are thought to increase vulnerability to gambling disorder. Specifically, however, gender (being male), childhood exposure to gambling, having friends and/or family who gamble and being socially marginalised were identified as risk factors in conjunction with Indigenous status. Like Williams et al., use of specific gambling products increased vulnerability to disordered gambling and increased frequency of gambling, and fallacious beliefs were also identified as risk factors [174]. MacLean et al., (2019) investigated the social practice of gambling for two Australian Indigenous communities, finding similar antecedents to gambling as Williams et al. [172] and Sharman et al. [173] However, the socially embedded nature of gambling was identified as a key limiting factor in the relative impact of any harm reduction program. This is supported by Gupta et al., (2021) in their study of the impacts of gambling on the person who gambles as well as non-gamblers because of the socially embedded nature of gambling for both Indigenous and non-Indigenous peoples.

Older people

Two studies explicitly discussed risk factors for gambling-related harm in older people [99,100]. Heiskanen and Matilainen (2020) argue that significant historical changes to the nature of gambling from being for ‘a good cause’, like church raffles, to the current context of commercial gambling must be considered when viewing gambling-related harm in older people. Moreover, the deterministic understanding of gambling problems as a personal flaw can prevent recognition of problem gambling and subsequent help seeking. These risk factors are considered stronger indicators of problem gambling than gender and educational attainment. Elton-Marshall et al. (2018) investigated the impacts of loneliness and social isolation among older people, suggesting that older people who socialise and who were married were far less likely to have high Problem Gambling Severity Index (PGSI) scores than older people who were divorced or single with limited social networks.

Migrants

Wardle et al., (2019) provided a rapid review of literature related to gambling-related harm affecting migrants and migrant communities, outlining various motivators to gamble. In particular, acculturation and acculturative stress, the impact of advertising and level of access to gambling in the new country were identified as risks for increasing gambling-related harm [177]. Protective factors were identified as levels of disapproval of gambling among migrants, and religious and moral tenets. However, this may be outweighed by acculturative stress, availability of gambling and the impact of the immediate social environment [92]. Importantly, Wardle and colleagues were careful to point out the ‘harm paradox’ experienced by migrants. This is supported by Bramley et al., (2020) in their investigation of barriers and enablers to support services from the perspective of migrants and the organisations supporting them [178]. According to Bramley and colleagues, migrants were at greater risk of gambling-related harm due to a lack of a social safety net in the form of family and friends in their new country. The inability to access informal support and the impact of gambling loss may have broader ramifications than they do for local gamblers [179]. Moreover, the tendency for migrants to work in a cash economy may enable individuals to binge gamble, potentially driving the self-perpetuating ‘chase mode’ that can be exacerbated via limited ability to secure money within formal banking systems.

Women

There has been little research on women and gambling [180,181]; however, there is increasing evidence of the lived experience of gambling-related harm among women [182]. Sharman et al., (2019) in their systematic review of psychosocial risk factors referred to women as a discrete group, identifying availability and access as well as the social nature of gambling as risk factors for disordered gambling. Women seeking treatment were also more likely than women not seeking treatment to present with co-morbid psychological conditions like anxiety, depression and mood disorder, and substance-use disorder. Experiencing trauma and abuse, living in a violent relationship, having low self-esteem and poor coping skills were all shown to be of high prevalence. Aggression in female adolescents was hypothesised to be indicative of future risky gambling [173].

LGBTQIA + community

Only one study referred to risk factors evident in the LGBTQIA + community, specifically trans and gender diverse (TGD) teenagers [183]. Rider et al., (2019) conducted a prevalence study of TGD youth in comparison to cis gender adolescents finding that assigned male sex at birth, regardless of gender transition, was a positive risk factor for developing problem gambling behaviours.

Discussion

This rapid synthesis evidence review included 166 peer reviewed studies about programs designed to address gambling-related harm. Most of the included studies referred to individual risk and protective factors, like socioeconomic position, age, and ethnicity, of people who gamble and explored how those factors may have contributed to overall gambling outcomes. Although there is an emerging body of evidence dedicated to public health approaches to gambling-related harm, there is a clear gap in empirical research findings around effective interventions to reduce gambling-related harm, particularly from a public health perspective.

Public health approaches to high-risk behaviours examine the social and environmental elements around the individual that may contribute to the likelihood of experiencing harm [184]. Examining gambling-related harm as a social concept is relatively new in comparison to focusing on the individual in isolation from their social context [80]. Much of the evidence included in this review focused on programs designed to address ‘problem gambling’ while identifying predisposing social and individual factors. Public health approaches to harm reduction centralise the individual within their social context while actively examining the various social determinants influencing that individual [6]. Very few of the included programs that focused on the individual demonstrated efficacy in the absence of support structures put in place around the individual. Predominantly, the included evidence outlined behaviour change mechanisms without support for the individual in their social context. This is a clear omission as the success of public health approaches to other high-risk activities like alcohol and other drugs are well documented [184].

Gambling-related harm is inherently determined by social context and industry/commercial influence on individual behaviour and choices [185]. By taking a public health approach, programs depart from an addiction focus to appreciate the far broader group of people experiencing gambling-related harm but who do not reach thresholds for addiction [186]. Most importantly, harm reduction also includes the numerous ‘affected others’ who bear the secondary impact of gambling-related harm ⁴.

Evidence supporting a public health approach for gambling-related harm is still developing but increasing. Findings from this rapid review described programs designed to respond to individuals whose behaviour is described as problem gambling (tertiary prevention), with variable effect on gambling behaviours and the individual’s experience of harm and no overt broader harm reduction approaches. Harm reduction programs generally seek to achieve primary or secondary prevention. Removing supply (primary prevention) is less likely in the context of a community that has liberalised gambling; however, targeted programs for harm reduction (secondary prevention) are far more likely to reduce overall harm experienced at an individual, community or population level. Wardle et al., (2019) argue that any interventions designed to address gambling-related harm must incorporate key understandings of the commercial, policy and regulatory environment that contribute to gambling exposure and subsequent harm. Gambling harms are related to increasing social disadvantage, with those who are less able to afford the monetary loss experiencing greater harm. Given the complex interplay between supply, social factors and individual behaviour, a public health approach may offer a more effective mechanism to reduce gambling-related harm. To optimise harm reduction outcomes in a liberalised gambling environment, public health programs should be implemented on a larger scale.

Conclusion

From this rapid literature review, two distinct discourses around gambling-related harm and effective interventions were apparent. First, a discourse around harm reduction and ‘responsible gambling’ that focuses on the ‘problem gambler’ as an individual, without recognising the broader context of commercial and social factors and harms. This discourse is seen most strongly in the tertiary prevention literature. Second, the smaller, yet emerging, discourse dedicated to preventing and reducing gambling-related harm that acknowledges the socially and commercially constructed nature of gambling and associated harms. This discourse was more likely to be to present in the primary and secondary prevention literature.

There was a clear paucity of empirical evidence related to effectiveness of programs that address gambling-related harm, particularly those that target primary or secondary prevention. By adopting a public health approach when addressing a complex issue like gambling-related harm, efforts to reduce harm are optimised are only possible in the context of sound evidence. Similar harm reduction areas like alcohol and other drugs equally rely on sound evidence to produce the positive outcomes evident in that field.