National Guide

Chapter 2 | Healthy living and health risks

Gambling







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      7. Gambling

Healthy living and health risks | Gambling

Dr Nicola Coalter, Mr Ashley Gordon  

Key messages

  • Gambling and gaming disorders are recognised as behavioural addictions and are included in the World Health Organization’s International classification of diseases 11th revision (ICD-11).1
  • In addition to harmful forms of gambling, including pokies, casino games, race betting and sports betting, a convergence of gaming and gambling products has given rise to a critical consumer vulnerability.2 Simulated gambling is now common in computer games with gambling components, such as loot boxes and social casino games where real money can be spent.
  • Ongoing participation in gambling or gaming can lead to addiction and harm.2 Approximately 25–35% of Aboriginal and Torres Strait Islander people currently gamble at harmful levels, and many are also harmed by other people’s gambling.3,4 However, few people seek professional help.
  • There is little understanding of what constitutes ‘best practice’ in gambling harm reduction for Aboriginal and Torres Strait Islander peoples, families and communities. Research indicates that Aboriginal communities respond better to Aboriginal-owned and -operated organisations.5,6
  • Primary healthcare is often someone’s first contact with the healthcare system.7 Because people generally trust relationships with healthcare professionals, research suggests this setting is essential for gambling screening and referral for treatment.7
  • The use of a validated screening question can identify people experiencing gambling harm, initiate a conversation and empower people to talk about their gambling safely.
  • Shame, stigma and lack of awareness of available support services are barriers to seeking help. When help is sought for gambling problems, it is primarily informal (eg seeking family support8). Therefore, screening for gambling harm can identify people who may have associated comorbidities and/or benefit from referral to services.9
Type of preventive activity - Screening
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
All people aged 12 years and over Ask patients if they participate in gambling or gaming activities (eg sports betting, wagering, card playing, pokies, casino gambling, online gambling/gaming, gaming). This enables people to talk about gambling safely

Ask patients the screening question, ‘In the past 12 months, have you or someone close to you had any issues with gambling?’

If harm is identified, consider most appropriate referral option (see Useful resources))		 Opportunistically Good practice point Screening tool and training pilot9
National guideline10		 Gambling may be masked by other health concerns, so it can be difficult to identify harms associated with gambling until significant harm is done

Routinely screening clients in crisis for gambling harm is important
Children who are in the care of people who are experiencing gambling harm Assess wellbeing and safety (see Chapter 4: Child and family safety) Opportunistically Good practice point Systematic review11 Child neglect and abuse can be direct consequences of parental gambling, and gambling harm can have long-term implications for children
Type of preventive activity - Behavioural
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
All people with ‘at-risk’ gambling/problem gambling Consider management options for problem gambling, including:
  • brief intervention and motivational interviewing aimed at supporting behaviour change
  • cognitive behavioural therapy
  • treatment of co-occurring and complicating factors such as depression and substance use
  • referral to gambling support helplines and websites (see Useful resources) )
  • referral to non-specialised gambling support (eg financial counselling and support, legal support services; see Useful resources))
  • referral to specialised gambling treatment (see Useful resources) )
 As clinically indicated Good practice point Systematic review12 Gambling harm can lead to financial, emotional, social, occupational and physical harm

Many cases of problem gambling/disordered gambling go undetected due to limited assessment of this problem
Type of preventive activity - Environmental
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
Community groups and schools Encourage teachers, parents and healthcare professionals to be more aware of adolescent gaming and gambling through the implementation of school-/sports-based gambling prevention strategies Opportunistically Good practice point Literature review and gap analysis13
Single study14		 Young people sometimes get into difficulties through their own gambling. They can also be affected by gambling in the household. Teachers and school staff may be able to respond with information and support, and, if necessary, refer young people to appropriate services for help
Community based Engage in community-focused activities (eg community-driven campaigns) that promote safer gambling strategies and rules Opportunistically Good practice point Aboriginal and Torres Strait Islander-specific project report15

Aboriginal and Torres Strait Islander-specific health promotion framework16		 Community engagement activities draw on health promotion principles to reach communities, drive impact and achieve outcomes through integrated partnerships and collaborations with other community and health organisations
  • Provide staff training about gambling harm: health professionals outside of gambling help services are more likely to be the first point of contact for people seeking help for problems relating to harmful gambling.
  • Invest in strengthening referral pathways between health services and non-specialised and specialised gambling support and treatment services.
  • Provide staff training about cultural awareness and cultural safety training. Each community is culturally unique; therefore, ongoing commitment to deepening cultural awareness and staff competency is essential to build an understanding of gambling and gambling harm for Aboriginal and Torres Strait Islander people.
  • Ensure staff understand the screening question, use it and know about available referral services.
  • Clinical audits could include reviewing the completion of the gambling screening question in annual health checks and whether there was appropriate follow up or referral.
  • People with a high level of distress (eg Kessler Psychological Distress Scale [K10] results) could be experiencing gambling harm; therefore, this is an opportunity for screening and making appropriate referrals for patients to non-specialised or specialised gambling help services.
  • Consider the promotion of gambling harm awareness within the service by displaying gambling health promotion materials, including signs of harmful gambling.
  • Promote gambling support services within the health service by providing information on non-specialised and specialised gambling services (eg financial wellbeing/counselling).

Clinical guidelines

Self-help tools

Education and training

 Community resources and services

National telephone counselling services:

  • Gambling Help Online 1800 858 858
  • National Debt Helpline 1800 007 007
  • Gambler's Help Youthline 1800 262 376
  • 13YARN (crisis support service for Aboriginal and Torres Strait Islander people) 13 92 76

Background

People participate in gambling activities for emotional, social, intellectual and monetary reasons.17,18 Gambling is defined as any activity where someone stakes money (or something of economic value) on an event with an uncertain outcome that is largely or entirely achieved by chance in the hope of winning money or something of value that they did not have before.19–21 

Gambling is common in Australia, with prevalence studies showing that approximately 60% of adults gamble at least once a year.3,22,23 Approximately 40% of Aboriginal and Torres Strait Islander people gamble once a week or more often.24 The most popular forms of regulated gambling in Australia are ‘Lotto’ and other lottery games, instant scratch tickets, poker machines (pokies), betting on horse or dog races, sports betting, keno and casino table games.25 Online gambling is the fastest-growing mode of gambling in Australia. More than one in 10 (11%) Australians in 2023 indicated they gambled online in the past six months, including on smartphones that enable people to bet anywhere, anytime.26 Australians lost approximately $25 billion on legal forms of gambling in 2018–19, representing the world's largest per-capita losses.27 

The prevalence of problem gambling in Australia has doubled in the past 10 years, and problem gambling causes significant harm.22 Gambling harm extends beyond the person who gambles, affecting others, including loved ones, children and families, and this harm can extend throughout whole communities.5,27,28 Prevalence studies show that potentially six other people are likely to be adversely affected by one person’s excessive gambling. 8 

Gambling in Aboriginal and Torres Strait Islander communities has a long history in community life.5,18,27 Despite this history, knowledge about contemporary Aboriginal and Torres Strait Islander gambling is sparse.5 Gambling harm affects Aboriginal and Torres Strait Island people similarly to other population groups; however, this harm can be more pronounced because of the likelihood of trauma, intergenerational poverty and ongoing social disadvantage.5,29 

Available evidence suggests that up to one in five Aboriginal and Torres Strait Islander people may be experiencing problem gambling,27 and up to 15 others in their lives are likely to be negatively affected.2 Gambling harm extends beyond a person’s financial situation, with established links between gambling and:

  • the problematic use of alcohol and other substances30
  • psychological distress and mental health disorders, including stress, anxiety, depression and low self-esteem30–32
  • suicidal ideation, suicide attempts and death by suicide30,33
  • intimate partner and family violence34,35
  • child neglect and abuse30,34
  • reduced parenting capacity, including inconsistent discipline, poor role modelling and financial and emotional deprivation34
  • physical health problems manifesting from psychological distress32
  • reduced work productivity, unemployment, bankruptcy and crime.18

Family dynamics relating to parents’ gambling are complex. Child neglect and abuse can directly result from parental gambling, and gambling harm can have long-term implications for children.30 As with other addictive behaviours, children whose parents (and other family members) have gambling disorders are at a higher risk of experiencing gambling harm.16 

Problem gambling has been repeatedly shown to be highly associated with depression, anxiety, suicidal ideation and substance use concerns.12,17,30 Environmental risk factors for problem gambling and related harm include the cultural and social normalisation of gambling, exposure to peer and family gambling, experiencing a ‘big win’ early on in gambling and introduction to gambling at an early age.5,26,36 

Young people who gamble are at high risk of gambling harm, with problematic behaviours at the same or higher rates than adults who gamble.13,14 Gambling problems among young people who gamble can lead to criminal behaviour, poor academic achievement, non-attendance at school, financial problems, depressive symptoms, suicide, low self-esteem, deterioration of social relationships and substance use.13 Some signs indicating young people may be experiencing harm from gambling and gaming include multiple visits to internet gaming sites, engagement in simulated gambling, purchasing instant lottery tickets, excessive interest in sports events and the game's odds, significant unexplained monetary outlays and time spent gaming.5,14 Family cohesiveness and school connectedness may protect adolescents against developing problems with gambling and gaming.15 

Aboriginal and Torres Strait Islander health services are strong leaders in providing culturally appropriate healthcare to improve health outcomes for people, families and the community. Therefore, recognising and responding to gambling harm is well placed within these services.15 

Significant changes from the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people third edition recommendations are as follows:

  • The addition of a single screening question about gambling in annual health checks for Aboriginal and Torres Strait islander people (see below).
  • Recognition that most gambling harm measurement tools emphasise screening for problem gambling rather than measuring the range of harms that can occur due to gambling. 

Consistent with gaps in understanding gambling harm, there is also a gap in understanding gambling in culturally diverse populations. Community-led approaches informed by principles of empowerment and cultural safety have been most helpful in raising awareness and preventing harm.8 

Often, problems with gambling can develop because of intergenerational trauma and loss of connection in a person’s life. Therefore, referrals to local cultural programs and healing services can help prevent further harm. 

Although not culturally validated, there are a number of self-help tools available to people (see Useful resources).

Screening

Measuring gambling harm is difficult with Aboriginal people because of poor socioeconomic conditions in communities, ongoing generational disadvantage, other complex problems and a general acceptance that ‘being broke’ is normal and not only a result of too much gambling.5,15,24,29

If you think a patient may be experiencing harm from gambling, asking the screening question can initiate a conversation about gambling and permit patients to talk about gambling safely.9,37 This screening question is validated as having a 92% detection rate for identifying gambling harm in patients in primary and allied healthcare settings.9 It identifies people who may benefit from referral to tailored support options.

The question is, ‘In the past 12 months, have you had an issue with gambling?’.9 This question has been adapted in current recommendations for inclusion in Aboriginal and Torres Strait Islander people’s annual health check (Medicare Benefit Schedule Item 715) as, ‘Have you or someone close to you ever had issues with gambling? Yes? No? Details.’

  1. World Health Organization (WHO). International classification of diseases, 11th revision. WHO, 2019 [Accessed 16 April 2024].
  2. Kolandai-Matchett K, Wenden Abbott M. Gaming–gambling convergence: Trends, emerging risks, and legislative responses. Int J Ment Health Addict 2022;20(4):2024–56. doi: 10.1007/s11469-021-00498-y.
  3. Browne M, Rockloff M, Hing N, Russell A, Boyle CM, Rawat V. NSW gambling survey 2019. Central Queensland University, 2019 [Accessed 16 April 2024].
  4. Stevens M, Gupta H, Flack M. Northern Territory Gambling prevalence and wellbeing survey report, 2018. Menzies School of Health Research, 2019 [Accessed 29 April 2024].
  5. Hing N, Breen H, Gordon A, Russell A. Risk factors for problem gambling among Indigenous Australians: An empirical study. J Gambl Stud 2014;30(2):387–402. doi: 10.1007/s10899-013-9364-y.
  6. Durey A, McEvoy S, Swift-Otero V, Taylor K, Katzenellenbogen J, Bessarab D. Improving healthcare for Aboriginal Australians through effective engagement between community and health services. BMC Health Serv Res 2016;16(1):224. doi: 10.1186/s12913-016-1497-0.
  7. Australian Institute of Health and Welfare (AIHW). Primary health care: Overview. AIHW, 2024 [Accessed 16 April 2024].
  8. Gupta H, Stevens M. ‘It started 30 years ago, and it still haunts me’: An exploratory investigation of Territorians’ gambling behaviours, harm, and help-seeking for gambling issues in an Australian jurisdiction. BMC Public Health 2021;21(1):96. doi: 10.1186/s12889-020-10141-5.
  9. Victorian Responsible Gambling Foundation (VRGF). One simple question on the path to recovery. VRGF, 2022 [Accessed 16 April 2024].
  10. Thomas S, Merkouris S, Dowling NA, et al. Guideline for screening, assessment and treatment in problem gambling. Med J Aust 2011; 195(11–12):664–65. doi: 10.5694/mja11.11088.
  11. Suomi A, Lucas N, Dowling N, Delfabbro P. Parental problem gambling and child wellbeing: Systematic review and synthesis of evidence. Addict Behav 2022;126:107205. doi: 10.1016/j.addbeh.2021.107205.
  12. Cowlishaw S, Merkouris S, Dowling N, Anderson C, Jackson A, Thomas S. Psychological therapies for pathological and problem gambling. Cochrane Database Syst Rev 2012;11:CD008937. doi: 10.1002/14651858.CD008937.pub2.
  13. Riley BJ, Oster C, Rahamathulla M, Lawn S. Attitudes, risk factors, and behaviours of gambling among adolescents and young people: A literature review and gap analysis. Int J Environ Res Public Health 2021;18(3):984. doi: 10.3390/ijerph18030984.
  14. Calado F, Alexandre J, Rosenfeld L, Pereira R, Griffiths MD. The efficacy of a gambling prevention program among high-school students. J Gambl Stud 2020;36(2):573–95. doi: 10.1007/s10899-019-09908-2.
  15. Aboriginal Health and Medical Research Council (AH&MRC) of New South Wales. Pressing problems: Gambling issues and responses for NSW Aboriginal communities. AH&MRC, 2008 Pressing Problems Community Reportcolor.pdf [Accessed 16 April 2024].
  16. Fogarty M, Coalter N, Gordon A, Breen H. Proposing a health promotion framework to address gambling problems in Australian Indigenous communities. Health Promot Int 2018;33(2):367.
  17. Binde P. Why people gamble: A model with five motivational dimensions. Int Gambl Stud 2013;13(1):81–97. doi: 10.1080/14459795.2012.712150.
  18. Productivity Commission. Gambling (2010): Inquiry report. Australian Government, 2010 [Accessed 2 May 2024].
  19. Macey J, Hamari J. Gamblification: A definition. New Media Soc 2022;26(4):2046–65. doi: 10.1177/14614448221083903.
  20. Latvala T, Lintonen T, Konu A. Public health effects of gambling – debate on a conceptual model. BMC Public Health 2019;19(1):1077. doi: 10.1186/s12889-019-7391-z.
  21. National Research Council (US) Committee on the Social and Economic Impact of Pathological Gambling. Pathological gambling: A critical review. National Academies Press, 1999. doi: 10.17226/6329.
  22. Hing N, Russell AMT, Browne M, et al. The second national study of interactive gambling in Australia (2019–20). Gambling Research Australia, 2021 Gambling Study.pdf [Accessed 16 April 2024].
  23. Rockloff M, Browne M, Hing N, et al. Victorian population gambling and health study (2018–19). Victorian Responsible Gambling Foundation, 2019 [Accessed 16 April 2024].
  24. Hing N, Breen H, Gordon A, Russell A. The gambling behaviour of Indigenous Australians. J Gambl Stud 2014;30(2):369–86. doi: 10.1007/s10899-013-9358-9.
  25. Australian Institute of Health and Welfare (AIHW). Gambling in Australia. AIHW, 2023 [Accessed 6 June 2023].
  26. Department of Social Services. Communities and vulnerable people. Gambling. Australian Government, 2023 [Accessed 6 June 2023].
  27. Queensland Government Treasury. Australian gambling statistics. Queensland Government Statistician's Office, 2020 [Accessed 16 April 2024].
  28. Langham E, Thorne H, Browne M, Donaldson P, Rose J, Rockloff M. Understanding gambling related harm: A proposed definition, conceptual framework, and taxonomy of harms. BMC Public Health 2016;16(79):80.
  29. Stevens M, Young M. Betting on the evidence: Reported gambling problems among the Indigenous population of the Northern Territory. Aust N Z J Public Health 2009;33(6):556–65. doi: 10.1111/j.1753-6405.2009.00453.x.
  30. Suomi A, Bailey M, Lucas N, Dowling N, Delfabbro P. ‘It’s like you’re not even there…’: Gambling harm experienced by children of gambling parents. Child Youth Serv Rev 2023;145:106800. doi: 10.1016/j.childyouth.2022.106800.
  31. Menzies School of Health Research. 2018 Northern Territory gambling prevalence and wellbeing survey. Menzies School of Health Research, 2019. Avaialble at [Accessed 17 May 2024].
  32. Hing N, Nuske E, Gainsbury SM, Russell AMT. Perceived stigma and self-stigma of problem gambling: Perspectives of people with gambling problems. Int Gambl Stud 2016;16(1):31–48. doi: 10.1080/14459795.2015.1092566.
  33. Livingstone C, Rintoul A. Gambling-related suicidality: Stigma, shame, and neglect. Lancet Public Health 2021;6(1):e4–5. doi: 10.1016/S2468-2667(20)30257-7.
  34. Dowling N. The impact of gambling problems on families. CORE, 2014 [Accessed 16 April 2024].
  35. Hing N, O’Mullan C, Nuske E, et al. The relationship between gambling and intimate partner violence against women. ANROWS, 2020 [Accessed 16 April 2024].
  36. Whiteside M, Heyeres M, Maltzahn K, Griffin T, MacLean S. Intervening in Indigenous gambling: A systematic review of the literature. SAGE Open 2020;10(3). doi: 10.1177/2158244020947441.
  37. Department of Health and Aged Care. 715 health check. Australian Government, 2022 [Accessed 16 April 2024].




 

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