National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

Background

Gambling is defined as ‘an entertainment based on staking money on uncertain events driven by chance’.¹ Popular gambling activities in Australia include lotteries and lotto, electronic gaming machines (EGMs; poker machines or ‘pokies’), wagering on horse or dog racing, keno, bingo, sports betting, and betting on card games. Gambling is common in Australia, with 70–80% of Australian people reporting they have gambled at least once in the past year,^2,3 and 64% reporting participation in commercial forms of gambling.⁴ Total annual gambling expenditure in Australia in 2014–15 was an estimated $22 billion, with 50% of these losses being from poker machines, and gambling expenditure from sports betting increased by 30% between 2013–14 and 2014–15.⁵
Aboriginal and Torres Strait Islander people participate in a range of gambling activities, and many are regular gamblers.⁴ Of Aboriginal and Torres Strait Islander people who participate in gambling on EGMs, sports betting, online casinos and race wagering, an estimated 40% gamble weekly.⁶

Card game gambling has long been a part of community life in many Aboriginal and Torres Strait Islander communities,⁴  and some gamblers sustain significant losses. Participation and frequency of card game gambling is declining in some urban areas and has been replaced by commercial gambling in some regions.⁴  Gambling on poker machines is a common activity for both men and women and is often the highest spending gambling activity among Aboriginal and Torres Strait Islander peoples.⁴ 

Some people who gamble will experience negative impacts from their gambling. ‘Problem gambling’ has been defined as ‘difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others or for the community’.²  A range of tools have been developed to assess whether individuals are ‘problem gamblers’,²  and estimates of the prevalence of problem gambling will depend critically on which tools are used. An estimated 1–3% of the Australian population are problem gamblers,^2,3 with lower rates in Western Australia where there are no poker machines in clubs or hotels.² Approximately 75–80% of problem gambling is associated with the use of poker machines, and problem gamblers contribute 40% of all gambling losses on poker machines.² It has been estimated that one person with problem gambling will have negative impacts on an average of five to 10 other people.¹
Available evidence suggests that up to one in five Aboriginal and Torres Strait Islander people may have gambling problems,⁴  and that problem gambling can have serious consequences for individuals, families and communities.^7–9 Negative impacts of problem gambling for Aboriginal and Torres Strait Islander peoples are similar to those for other population groups, and can include financial hardship, relationship breakdown, social and emotional difficulties, substance misuse, impacts on employment and contact with the criminal justice system.^7,8 Problem gambling is highly associated with depression, anxiety, suicidal ideation and substance misuse.^2,10

Environmental risk factors for problem gambling include the cultural and social normalisation of gambling, exposure to peer and family gambling and introduction to gambling at an early age.^11–13 Children whose parents and/or siblings have issues with problem gambling or substance abuse are at higher risk of becoming problem gamblers.¹⁴ Adolescents who gamble are at particularly high risk for problem gambling, with problem gambling behaviours at two to three times the rate of adults who gamble.^11,12 There is limited information on the early identification of adolescents with gambling problems.¹² Warning signs of adolescent problem gambling include multiple visits to internet gaming sites, use of instant lottery tickets, excessive interest in sports events and significant unexplained monetary outlays.¹³ Family cohesiveness and school connectedness may protect adolescents from problem gambling.¹³

Interventions

Interventions to reduce harms caused by gambling can involve a broad group of stakeholders, including government, industry and community.^2,7,14,15 Public health approaches to address problem gambling promote structural interventions, such as safety controls for technology-based gambling and prevention of access to instant lottery tickets for those under 18 years. Such interventions may help reduce both the uptake of gambling and harms from gambling.^13,16–18
The goal of primary prevention activities for gambling is to encourage responsible and non-harmful gambling activities among people who choose to gamble.¹⁴ In Aboriginal and Torres Strait Islander communities, interventions to reduce harms from gambling are more likely to be effective if they include attention to the social, cultural and environmental context of gambling; take into account individual community needs; and promote whole-of-community health.^7,9 Community education that focuses on the risks of gambling, including negative impacts on children, and the recognition and availability of support and assistance for problem gambling, may be useful.⁴

Australian clinical guidelines published in 2011 provide guidance on the identification and treatment of problem gambling.³ Screening for problem gambling in the general population has been promoted to GPs and other primary healthcare practitioners, because primary healthcare settings provide a good opportunity for identifying people with, or affected by, problem gambling and linking them to support and treatment services.^16,19 Primary care workers may become more confident and effective at detecting problem gambling through recognising that people with gambling problems may present with stressrelated medical disorders or other symptoms, and that problem gambling is commonly associated with other health problems including substance abuse and mental health disorders.^16–18 It is also important to note that shame and stigma may prevent Aboriginal and Torres Strait Islander people from accessing help for gambling-related problems.⁷

A range of tools have been developed to identify and characterise problem gambling, although only a few are appropriate for screening people for problem gambling in primary healthcare settings.^3,10,16,18 The 2011 Australian clinical guidelines about screening for and treating problem gambling included a review of available screening and diagnostic tools for problem gambling, and recommended three brief screening tools as suitable for use in primary care settings – the Brief Bio-social Gambling Screen (BBGS), the Lie-Bet Questionnaire, and NODS-CLiP.³ The guidelines noted the successful use of a medium-length assessment tool, the EIGHT questionnaire, in general practice settings,²⁰ and a subsequently published study explored the adaptation of the nine-item Problem Gambling Screening Index (PGSI) to assess the prevalence of problem gambling in Aboriginal and Torres Strait Islander populations.²¹
A simple question about whether a person is experiencing problems with their gambling may be as effective as more complex tools and may be more appropriate for primary care screening.¹⁸ A tool designed to help Aboriginal Community Controlled Health Service (ACCHS) staff identify people who could benefit from information, support and referral about gambling was piloted in New South Wales in 2010.²² Using this tool, ACCHS staff were encouraged to ask attendees if they or someone they were close to had issues with gambling, and to offer information and support. A pilot of the screening tool, and resources to support staff with responses and referrals, was positively evaluated by staff at participating ACCHSs in terms of acceptability and usefulness.²³

More research is needed into screening and intervention for adolescents who gamble.²⁴ Most current research has been conducted in the context of school-based interventions.²⁴ Given gambling behaviours can begin at approximately 12 or 13 years of age, preventive interventions, such as school-based strategies educating youth on basic principles of gambling, should begin before then.^14,25 Increasing the awareness of teachers, parents and healthcare professionals in recognising adolescent gambling may assist in the identification of at-risk adolescents.¹³
Systematic reviews and randomised controlled trial evidence provide some support for the effectiveness of psychological therapies for problem gambling, including cognitive behaviour therapy and motivational interviewing.^3,26–28
Aboriginal and Torres Strait Islander health services can contribute to improving the detection and management of problem gambling in their communities by training their staff to identify and respond to gambling issues, and by strengthening referral pathways between their health service and local gambling support and treatment services.⁷