In this piece, we explore the issue of problem gambling from a public health perspective, specifically through a health equity lens, and share important considerations and action items as we work to reduce stigma and address the disproportionate impact of problem gambling on Black, Indigenous, and People of Color (BIPOC) and other marginalized communities.
Gambling is a human phenomenon that has existed for nearly as long as humans. Evidence of gambling can be found among ancient artifacts in many civilizations. It is present in all identities, cultures, and social strata. And as long as there has been gambling, there has also been problem gambling. Problem gambling is defined as any gambling behavior patterns that compromise, disrupt or damage personal, family, or vocational pursuits, and can include sports and race betting, lottery, online gambling, and bingo. Problem gambling has broad social, economic, and health impacts on individuals, families, and communities and does not have to meet diagnostic criteria for gambling disorder to cause problems. It is sometimes called “the hidden addiction” as it has no physical symptoms, though it frequently co-occurs with other mental health and substance use disorders. As many as 96% of people with problem gambling also meet criteria for another mental illness. Problem gambling has the highest rate of suicide of any addictive disorder, with 1 in 5 attempting suicide. The National Council on Problem Gambling estimates that $7 billion is spent annually in the U.S. related to the social costs of problem gambling, including job loss, criminal justice involvement, and healthcare expenditures. Currently, about 1% of the US adult population struggles with problem gambling, with many more at risk.
Why Problem Gambling is a Public Health and Health Equity Issue
Problem gambling, along with other process disorders or compulsions, can be difficult to understand. The physiological and neurological responses to gambling behavior are similar to those that occur in substance use and can result in clinical addiction for those who are predisposed. As with other behaviors, an individual’s gambling is also influenced by family, community, culture, and social conditions. At the population level, increased risk of problem gambling can be seen in people with substance use disorders, seniors, youth, veterans, low-income, and BIPOC individuals. The convergence of stigma, targeted marketing, and social conditions in BIPOC communities has resulted in disparate harm from problem gambling. Since problem gambling is intertwined with mental health, substance use, and systemic racism, using a public health approach with an equity-informed lens considers both prevention and treatment while focusing on the systemic inequities that contribute to the disproportionate burden of problem gambling on marginalized communities
Addressing Barriers to Treatment for Problem Gambling
There are numerous barriers to addressing the issue of problem gambling. Some of the most evident barriers to treatment are:
- Low awareness about problem gambling, its symptoms, and available treatment among providers and the general public;
- Limited capacity among qualified behavioral health providers to deliver problem gambling treatment services, particularly care that is linguistically appropriate, culturally competent, and inclusive of intersecting identities; and
- Stigma and shame prevent individuals from self-identifying as having problem gambling and seeking treatment.
Since problem gambling often co-occurs with substance use and mental health disorders, some examples of a public health and equity-informed approach would:
- Increase awareness and build screening and treatment capacity among existing behavioral health providers;
- Partner with BIPOC-serving organizations to increase awareness and serve as trusted messengers in the community;
- Engage authentically with individuals who have lived experience to inform approaches, tailor messaging, and identify potential gaps in care.
Building the capacity needed to address problem gambling in the U.S. will require substantial strategic investment and coordination. However, unlike other behavioral health issues, there are no federal funds allocated to support problem gambling services; investments and funding decisions are left to state and local governments. While 40 states had invested in some sort of infrastructure to support problem gambling, only 17 states had funded one or more full-time state employees to administer problem gambling programs, with an average of just $0.37 cents per capita spent on services (which drops to $0.23 when including all 50 states and Washington, DC). In states where there is limited or no infrastructure, people in need of services are unlikely to be screened, and if they are, their treatment options are limited to whatever is covered through their insurance providers. Since BIPOC folks are less likely than their White counterparts to have sufficient health care coverage, this further widens health inequities.
The gambling industry continues to grow rapidly, with the U.S. reaching $44B in revenue in 2021. With broad expansion of legalized gambling opportunities (casinos, online gambling, etc.), gambling has become more accessible than ever. Growing public and clinical concern around problem gambling led to the launch of Problem Gambling Awareness Month.
Problem Gambling Awareness Month (PGAM)
Problem Gambling Awareness Month is a grassroots effort led by the National Council on Problem Gambling (NCPG) that aims to increase public awareness of problem gambling and encourage healthcare providers to screen clients for problem gambling annually during March. Its primary goal is to increase public awareness of problem gambling and the availability of prevention, treatment, and recovery services. Building on PGAM, the Cambridge Health Alliance’s Division on Addiction established Gambling Disorder Screening Day in 2014, now held every year on the second Tuesday of March (this year’s Screening Day was March 8, 2022). Providers who wish to learn more about screening for problem gambling can access the Gambling Disorder Screening Day Toolkit from the Cambridge Health Alliance’s Division on Addiction. People who think that they might have problem gambling can take this 5 question screener from the Massachusetts Problem Gambling Helpline. Throughout the month of March, HRiA, along with numerous other organizations in the field, has been posting regularly about problem gambling on social media using the hashtag #PGAM2022.
Important Considerations and Action Steps
Understanding the insidiousness and burden of problem gambling should be an area of focus throughout the year. Whether you work specifically in public health or are touched by this issue in your personal life, there are several action steps we all can take:
- Call a Gambling Helpline if you, a friend, or family member needs support: HRiA manages the MA Gambling Helpline which links people to recovery services. A list of resources in other states can be found here.
- Build awareness and capacity around problem gambling among your colleagues: Demystifying problem gambling and understanding its relationship to other conditions and disproportionate burden in BIPOC communities can reduce stigma and reframe problem gambling within the larger public health field. Several of HRiA’s problem gambling capacity building initiatives that offer free resources:
- The MA Office of Problem Gambling Services supports HRiA’s work on two such initiatives: the Massachusetts Technical Assistance Center for Problem Gambling (M-TAC), which builds capacity among providers to identify and treat program gambling, and Project Build Up (PBU), a problem gambling workforce development program. In addition to building the problem gambling workforce, M-TAC administers the Massachusetts Problem Gambling Specialist (MA-PGS) program, the official gambling treatment certificate in the Commonwealth, and PBU provides grant and scholarship opportunities to become MA-PGS certified and pursue professional development opportunities to strengthen the capacity of the behavioral health workforce to provide or promote gambling treatment services. Lastly, HRiA’s newly launched Behavioral Health and Racial Equity (BeHERE) Initiative provides a central location for our trainings, resources, and education content.
- Engage authentically with impacted communities and people with lived experience so that approaches and messaging are driven and validated by those most affected: Authentic engagement ensures that problem gambling prevention and treatment efforts are appropriate (linguistically, culturally, and informed by lived experience) and support the intended outcome. This approach has been shown to work for problem gambling as well as other related mental health conditions like suicidal tendencies. The Suicide Prevention Resource Center offers many resources on how to engage people with lived experience. HRiA’s blog post on community engagement through assessment and communication planning tools are just a few helpful resources available to support this important work.
- Advocate for policy and systems change around problem gambling: Policy and systems change provide the backbone infrastructure for prevention and recovery efforts. However, there is a lack of consistent and sustained infrastructure and funding for problem gambling around the U.S. NCPG provides a list of tools and resources on how to advocate for increased funding and stronger policies to address problem gambling.
HRiA is committed to supporting and transforming the problem gambling and public health fields. In the last several years, our assessment, evaluation, capacity building, training, and helpline services have contributed to amplifying voices with lived experience, creating and implementing comprehensive curriculum for providers, directing those in need to services, and examining trends and patterns to guide data-informed strategic initiatives, all with a focus on health and racial equity.
Learn more about problem gambling and some examples of various initiatives by visiting the resources below:
- MA Problem Gambling Helpline: gamblinghelplinema.org
- MA Technical Assistance Center on Problem Gambling: m-tac.org
- Project Build Up: hria.org/project-build-up
- Behavioral Health and Racial Equity (BeHERE) Initiative: behereinitiative.org