Global public health action is needed to counter the commercial gambling industry

The commercial gambling industry has become one of the most innovative health-harming industries of recent times. New digital technologies and affordable internet have enabled the rapid transformation of this industry and its ability to offer many high-intensity gambling products across the world (Akanle and Fageyinbo, 2019). These are readily accessible in land-based venues and online via mobile devices which are constantly available 24 hours a day. In low- and middle-income countries (LMICs), mobile betting, coupled with the weak or complete absence of regulatory enforcement also adds to gambling engagement, particularly among youth (Okoti et al., 2019; Sichali et al., 2023). Gambling harms can destroy lives, and the liberalization of gambling markets partnered with the highly sophisticated products and practices of the commercialized gambling industry means that harm can now occur even more rapidly and at a larger scale. There is ample evidence to show the significant negative health and social consequences of gambling not only for individuals who gamble, but also for families and communities. These include financial difficulties (Marko et al., 2023), family violence (Brambilla et al., 2023), homelessness (Vandenberg et al., 2022), criminality (Binde et al., 2022), psychological distress (Sinclair et al., 2015), comorbidities with substance misuse (Skaal et al., 2016), and suicide (Marionneau and Nikkinen, 2022), as well as disproportional health care utilization and associated economic costs (Cowlishaw and Kessler, 2016). Governments have been unprepared and complacent in dealing with the impact of rapid technological developments in the gambling industry. The absence of global approaches and conventions has also enabled the gambling industry to transcend geographical borders (Saeed et al., 2023). For example, African countries are strategically important growth markets for such health-harming industries (Bitanihirwe et al., 2022). Recent years have seen the expansion and diversification of commercial gambling in LMICs, as exemplified in Sub-Saharan Africa (SSA), where acute concerns have been raised about the role of Global North operators in capitalizing on a ‘regulatory void’ relating to online gambling and its promotion (Sichali et al., 2023). However, challenges faced by most LMICs include resource constraints, competing priorities, power imbalances and the inability to effectively regulate health-harming industries and the risks they pose. For example, while some regulatory measures exist in SSA for commercial gambling, in most countries these are inconsistent, lack transparent public reporting and require strengthening to stay abreast of advances in the industry (Sichali et al., 2023). The commercial gambling industry operates from a similar playbook to other health-harming industries, such as tobacco and alcohol (Cowlishaw and Thomas, 2018; Ulucanlar et al., 2023). This involves delaying and circumventing regulation, developing innovative products and promotions, appealing to new markets, co-opting the production of research and knowledge and capturing ‘public health’ responses through corporate political activities (van Schalkwyk et al., 2021). The digital determinants of health are also clear in relation to the gambling industry (Kickbusch and Holly, 2023). New technologies have enabled the industry to rapidly ‘create doubt and frame the public debate with devastating consequences’ for community health and wellbeing (Thomas and Daube, 2023, p. 2). As a result, the products, practices and promotions of the industry, coupled with poor regulatory responses from governments that also generate substantial revenue from gambling through taxation, pose widespread threats to global public health (Thomas et al., 2023c). Gambling prevention and services are rarely seen as a function of health departments. There is little by way of co-ordinated public health prevention, health promotion, or policy efforts that aim to prevent and reduce harms at a population level (Thomas et al., 2023c), or policies which address the preventable risks posed by the industry, and ensure that regulatory structures keep the community safe from harm to the greatest extent possible (Rae and Fell, 2022). Gambling is normalized through an interplay of socio-cultural, environmental, commercial and political processes which influence how gambling products are made available and accessible, encourage and routinize the regular use of these products, and embed gambling in everyday contexts (Thomas et al., 2018). The framing of gambling as a legitimate leisure activity that has many socio-cultural and economic benefits is itself an industry strategy that deflects attention away from the addictive qualities and harms associated with gambling products and environments (Marko et al., 2022). The industry and a variety of groups that benefit from gambling, including broadcasters, sporting organizations and some governments, have played major roles in the cultural construction and normalization of gambling. These actors have contributed to the increased social acceptance of gambling by making products widely available and accessible, using marketing and innovative technologies to encourage regular and routine engagement in gambling, and ensuring that gambling is seen as an accepted part of everyday life (Egerer and Marionneau, 2019). The availability and accessibility of land-based gambling venues in local neighbourhoods and recreational spaces has also contributed to the social acceptance of these venues (Bestman et al., 2020). This includes creating a perception that gambling is a normal leisure activity, with such contextual factors also influencing how some population groups conceptualize and negotiate the risks involved (McCarthy et al., 2021; Pitt et al., 2023). Gambling also enables large, increasingly multinational corporations to extract considerable profits from communities, while exacerbating disadvantage for those already vulnerable to health and social inequalities (Latvala et al., 2021). Venues are often clustered in areas of socio-economic deprivation (Pérez et al., 2022), and groups that are vulnerable to gambling harm, such as older adults and migrants, may be attracted to gambling venues which are promoted as ‘safe’ and inclusive spaces that are easily accessible in local communities (Pitt et al., 2021; Wu, 2023). The glorification of gambling as a source of income and wealth is also of particular concern in regions such as SSA territories where many young people already struggle to find opportunities for livelihood and social mobility amid high rates of ‘labour precarity and unemployment, including youth unemployment’ (Sichali et al., 2023, p. 143). This has the potential not only to increase gambling-related harm but to exacerbate social and health inequalities among marginalized demographics, entrenching poverty via the unilateral transfer of wealth outside local communities. Technology and the embedding of gambling in sport (including through major sponsorship deals) have enabled the online gambling industry to normalize young men’s engagement with its harmful products (McGee, 2020). The industry is also rapidly diversifying its markets. As has occurred with the tobacco and alcohol industries, evidence suggests that the gambling industry is developing new products and promotions that appeal specifically to women (McCarthy et al., 2022); for example, via the introduction of novelty markets which allow betting on reality television and awards shows, as well as gambling advertising that features women heavily across television and social media marketing (Belot, 2023; McCarthy et al., 2022). These new online formats may make gambling more accessible, available and routinized for women (Thomas et al., 2022). Inadequate action from policy makers on the marketing of new generations of gambling products means that gambling should also be viewed as an intergenerational justice issue. Betting on minors in sporting events has also only recently been banned in the state of Victoria, Australia (Victorian Gambling and Casino Control Commision, 2023). Children and young people are increasingly exposed to omnipresent and innovative gambling marketing in a range of online and community settings (Smith et al., 2020; Thomas et al., 2023a, b). This often features endorsement by celebrities and sporting heroes, shaping positive attitudes towards products, and encouraging the rapid normalization of gambling for youth (Egharevba et al., 2023; Nyemcsok et al., 2018). Brand exposure in public spaces has increased significantly, with new products often seeking to engage an expanding youth population via the popular cultural medium of sport fandom. A recent study in Malawi—which ranks among the lowest-income countries in the world—revealed how high-visibility advertising via roadside billboards and lamppost adverts in urban centres were combined with the sponsorship of local sports teams, associations with European football, and the media promotion of winners’ stories to establish a broad customer base, including among youth demographics (Bunn et al., 2020). While there has been growing recognition of the tactics employed by health-harming industries such as tobacco, alcohol, ultra-processed foods and fossil fuels (Gilmore et al., 2023; McCarthy et al., 2023), there has been less recognition of similar concerns about gambling. A range of powerful vested interests have contributed to ensuring an ‘exceptionalism’ in gambling research, policy and regulation (Orford, 2019), as a result of which the gambling industry has not been held to the same standards by either governments, some researchers and community organizations. For example, while much action is still required to counter the efforts of tobacco and alcohol industries, a range of government policies in these areas have sought to prioritize public health and wellbeing through measures addressing advertising, packaging, labelling, taxation, access and supply (Greenhalgh et al., 2022; Burki, 2023). By contrast, policies notionally targeting harms from gambling have remained stubbornly focussed on behavioural addiction, ‘informed choice’ and ‘responsible gambling’ approaches to harm minimization that place the individual at the centre of the narrative about responsibility for harm (van Schalkwyk et al., 2019), and do little to alter environments to protect children and young people from widespread gambling marketing. This approach (which now includes the revised ‘safer gambling’ paradigm) is beneficial for both the gambling industry and government as it reduces their accountability and role in preventing harm, while simultaneously preserving the mechanisms which normalize gambling to drive profits. There is especial cause for concern about the conflicts of interest that exist in all areas of gambling research, education and treatment (Cassidy et al., 2013). There has long been recognition of the need to protect public policy on tobacco from vested interests. The World Health Organization Framework Convention on Tobacco Control, ratified by 183 jurisdictions since its adoption 20 years ago, specifically seeks to protect countries’ public policy from being influenced by vested interests. Article 5.3 commits these countries to ‘…protect their public health policies related to tobacco control from commercial and other vested interests of the tobacco industry in accordance with national law’, with the Guidelines noting that there is ‘…a fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests’ (World Health Organization, 2003). However, no equivalent mechanisms have been developed for gambling. In the absence of such protections, the industry has lobbied all levels of government with few constraints (Stacey and Walker, 2023), and regularly funds academic research either directly or indirectly through industry-funded third-party organizations (often registered as charities) (Cassidy, 2020). This practice has provided the industry with opportunities to enhance optics of ‘corporate responsibility’ and legitimise its role in providing responses to the problems they have caused (Nikkinen, 2019). This has also distorted the nature of research that has been produced and skewed towards the interests and objectives of the gambling industry which may have a ‘profound impact on knowledge, policymaking and public health’ (Marks, 2019, p. 76). The industry has also pursued a questionable right to have a seat at the table in relation to discussions about how to minimize the harms associated with its products. Industry actors are involved regularly in government advisory groups, and are invited to participate in consultations and decisions about regulations and policies that directly impact their operations (Liquor and Gaming NSW, 2023). Finally, the industry regularly sponsors and attends academic (and related) conferences and events which promote industry-friendly framings and ‘science-wash’ the industry through minimizing the contribution of the gambling industry to harm (Dun-Campbell et al., 2023). It also funds and promotes its involvement in ‘education’ activities and treatment services—even with children. Analyses have shown that these programs reinforce industry narratives and educate children about becoming ‘responsible consumers’ of gambling (van Schalkwyk et al., 2022). Such Corporate Social Responsibility strategies are part of a broader suite of marketing initiatives, alongside lobbying practices and political donations, which enable the gambling industry to push self-regulation and avoid effective and meaningful evidence-based regulation (Thomas et al., 2023b). The political will of governments to enact policies and legislation to address harmful industries can have a transformational impact on population health and wellbeing. The historical template of tobacco demonstrates that global public health approaches that seek to protect current and future generations from a predatory industry can have major impacts on health and prevent harm (McHardy, 2021). As the independent evidence about the harms associated with the gambling industry accumulates, some governments and gambling regulators have appeared to approach a tipping point regarding the amount of harm they and, perhaps most importantly, the community are prepared to tolerate. Unfortunately, the strong financial interests of the beneficiaries of gambling may hinder the adoption of sensible and proportional public health policies (Marionneau and Nikkinen, 2020). Transformative approaches to the regulation of the gambling industry are nevertheless now being proposed or acted upon in some countries as part of public health approaches. This involves recognizing that the gambling industry is a key vector of harm (Victorian Gambling and Casino Control Commission, 2023), banning gambling advertising in order to protect children (Leulmo and Pinedo, 2020), and advocating for multinational agreements to prevent regulatory capture and protect public policy and research from vested interests (Standing Committee on Social Policy and Legal Affairs, 2023). In Belgium, for example, new legislation and tax rules prohibit gambling companies from deducting sponsorship expenses, in a similar manner to other companies (FPS Justice Gaming Commission, 2023). These are important steps in paving the way to more effective gambling regulation. However, in other countries there are significant regulatory voids, particularly relating to digital forms of gambling and gambling promotions (Sichali et al., 2023). The Ottawa Charter for Health Promotion involves a focus on key principles of equity and social justice, as well as building policies and environments that promote the health and wellbeing of communities. It specifically directs policy makers to be ‘aware of the health consequences of their decisions and to accept their responsibilities for health’ (World Health Organization, 1986). However, this is not just the role of policy makers, but of public health professionals more broadly, and communities as well. Public health and health promotion efforts should advocate for the recognition of gambling harm as a significant public health concern, ensuring it receives the attention and resources it requires in line with other public health issues. Leadership from the public health community is needed to advocate for a comprehensive approach to gambling harm prevention, recognizing the industry as the key vector of harm. This would include independent (i.e., free from gambling industry influence) policies and strategies based on precautionary principles that prioritize health and wellbeing, and protect individuals, their communities, and families from being harmed by the gambling industry, its products, and practices (Thomas et al., 2023c). As a first step, we must acknowledge the legacy that industry funding and influence, and a lack of government willingness to act has had on all aspects of gambling research, policy, and practice. While shifting established practices takes time, any efforts to counter the commercial gambling industry must apply the same scrupulousness that we apply to the tobacco industry and how we interact with it, or not. This includes rejecting commercial gambling industry research funding and partnerships, whether direct or indirect through its front groups and educational initiatives, and avoiding any involvement in industry funded and organized events other than for clearly defined observational research. We must move forward by learning from other fields, and how they gained their independence, and contributed to public health policy change that was once seen as impossible. Rather than a focus on problematic individuals and research that is palatable to governments, the gambling industry and its allies, we must shift our focus to questions that allow us to assess the impact of industry tactics, products and promotions, as well as researching how evidence is used by different policy actors, and the impacts of these policies on society. We must also exercise extreme caution in compromising the integrity of public health and health promotion principles and goals in pursuit of perceived short-term gains through collaborations with industry and its allies, or in which harm is tolerated if the industry pays for some of the damage it has caused (van Schalkwyk et al., 2023). Prohibited partnership policies should ensure that organizations do not accept funding or form relationships with the commercial gambling industry, and thus play no further role in legitimizing ‘ineffective industry-friendly interventions’ that only serve the interests of the industry and those who profit from it (Catford, 2012, p. 308). We would encourage other public health and health promotion journals to follow Health Promotion International’s lead in refusing to accept manuscripts funded either directly or indirectly by the commercial gambling industry. Finally, we must advocate for comprehensive public health approaches to gambling harm prevention that are based on core public health principles. New formats and outlets for public health research should focus on identifying and explaining the structural and commercial drivers of harm and inequities and how to prevent these. 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