PHE evidence review of gambling-related harms stokes the fire of the Gambling Act Review

In March 2018, the then Health Minister’s remit letter confirming the priorities of Public Health England (“PHE”) for 2018 to 2019 included a request for PHE to “inform and support action on gambling-related harm as part of the follow up to the Department for Digital, Culture, Media and Sport-led (DCMS) review of gaming machines and social responsibility”.

Three and a half years later – on 30 September 2021 – PHE published the first evidence review of gambling-related harms in England which – it says – “reveals harms associated with gambling estimated to cost society at least £1.27 billion a year”.

PHE concludes as follows:

This review has brought together and analysed the best available international research evidence on risk factors and gambling-related harms. The evidence suggests that harmful gambling should be considered a public health issue because it is associated with harms to individuals, their families, close associates and wider society.

Gambling-related harms have considerable cost to society, likely to be in excess of £1.27 billion.

The most socio-economically deprived and disadvantaged groups in England have the lowest gambling participation rates, but the highest levels of harmful gambling and they are also the most susceptible to harm. So, if there are no interventions to improve this situation, harmful gambling is likely to make existing health inequalities worse.

The harms identified in this report and the cost to society suggests that more needs to be done to prevent and reduce the harms associated with gambling.

It goes on to describe the “next steps” as follows:

To address gaps in this evidence base PHE is undertaking a Delphi study. This study aims to identify what policies and interventions could be adapted from public health to address the gambling-related harms identified in this review .

The Office for Health Improvement and Disparities will work in partnership with other government departments and key stakeholders to develop a workplan to:

  • address the knowledge gaps identified in this review
  • improve data collection
  • deliver effective and implementable responses to gambling-related harms

The following review documents (addressing the prevalence, risk factors and public health harms associated with gambling and the economic and social burden) can be (a) accessed via the following links or (b) downloaded below.

PHE’s press release states as follows:

Landmark report reveals harms associated with gambling estimated to cost society at least £1.27 billion a year

In 2019, the Department of Health and Social Care commissioned PHE to undertake a review of the evidence on gambling harms. The review includes the most comprehensive estimate of the economic burden of gambling on society to date, revealing that the harms associated with gambling cost at least £1.27 billion in 2019 to 2020 in England alone. This analysis includes the first estimate of the economic cost of suicide (£619.2 million) and provides an updated cost of homelessness associated with harmful gambling (62.8 million).

Gambling related harms in the analysis range from financial such as bankruptcy and employment issues, to family issues, and health harms such as suicide.

The review also shows that people at risk of gambling harms are concentrated in areas of higher deprivation, such as the North of England, and may already be experiencing greater health inequalities. The review found a clear link between higher levels of alcohol consumption and harmful gambling, with only 35.4% of non-drinkers participating in gambling compared to 74.4% of those consuming over 50 units of alcohol (equivalent to 16 pints of beer or large glasses of wine) per week. Alcohol use in children and young people was also found to be a risk factor for subsequent harmful gambling.

The review also highlights the link between gambling and mental health issues. The report found that gambling can increase the likelihood of some people thinking about, attempting or dying from suicide. Evidence suggests that people with gambling problems are at least twice as likely to die from suicide compared to the general population, with one overseas study showing that people with a gambling disorder had a 19 times increased risk of dying from suicide.

The review also found that gender and poor mental health were the strongest indicators of gambling related harm:

  • men were 4.2 times more likely than women to be gambling at levels of elevated risk of harm
  • people identified as having some mental health issues were twice as likely to participate in harmful gambling than people with no mental health issues
  • those who indicated they had a mental health condition were 2.4 times more likely to be a gambler experiencing gambling-related harms

The evidence suggests that harmful gambling should be considered a public health issue because it is associated with harms to individuals, their families, close associates and wider society with an approach that focuses on prevention, early intervention and treatment. The new Office for Health Improvement and Disparities (OHID) will work closely with other government departments, including the Department for Digital, Culture, Media and Sport (DCMS) and key stakeholders to develop a workplan to address the knowledge gaps identified in this review, improve data collection, and deliver an effective response to gambling-related harm.

Rosanna O’Connor, Director of Alcohol, Drugs, Tobacco and Justice at PHE, said:

There is so much more at stake from gambling than just losing money – from the toll on mental health to the impact on those around the gambler. The evidence is clear – harmful gambling is a public health issue and needs addressing on many fronts, with an emphasis on preventing these harms from occurring as well as with help readily accessible for those directly and indirectly affected by the wide ranging and long lasting negative impacts of gambling.

Minister for Mental Health, Gillian Keegan said:

Whilst the economic costs of harmful gambling are stark, the cost to individuals as a result of their addiction, and those around them, cannot be overstated. We are working to protect vulnerable people from the damaging impacts gambling can have, including through specialist NHS gambling addiction clinics and investing at least an extra £2.3 billion a year by 2023 to 2024 to expand mental health services. I encourage anyone who is struggling to reach out – support is there for you.

Gambling Minister Chris Philp said:

We are gathering all the necessary evidence to reset the balance between giving adults the freedom to choose how they gamble safely, with the right protections for those at risk of harm. We are determined to protect vulnerable people from exploitation by aggressive advertising or unfair practices that entrench problem gambling.

Jim McManus, Vice President, Association of Directors of Public Health said:

This evidence review from PHE paints a stark picture of the avoidable harms from gambling to the economy, society and the individual. Again, we see that existing regional inequalities are exacerbated by these harms with those from poorer areas at higher risk from the negative impacts. A public health approach, with cross-government support, properly funded, is essential to reducing harmful gambling and all the negative consequences highlighted by this research in relation to debt, relationships and jobs.

Tim Miller, executive director at the Gambling Commission said:

We are pleased to welcome this important independent report from Public Health England. Protecting people from gambling harms is a priority for the Gambling Commission, and we take a public health approach to do so. Public Health England’s work will help to support the continuing collaboration of a wide range of bodies under the National Strategy to Reduce Gambling Harms.

Faculty of Public Health President Professor Maggie Rae said:

Harmful gambling is a major public health issue which seriously impacts on health in a number of ways. As well as suicide and severe mental health problems, this report highlights harms caused by gambling including financial, employment, relationships, physical health, and criminal activity. Gambling organisations are preying on people’s addictions, and we see that the burden of gambling harms is borne by those already facing disadvantage, serving to widen existing health inequalities. This report is welcome as it highlights the wide range of harms caused by gambling, and calls for concerted action to tackle this major public health problem. This urgent call is especially timely as we have seen these problems exacerbated by the COVID-19 pandemic.

More information about the review, including the scope of the review and the terms of reference for the external reference group advising the review, can be found in PHE’s gambling-related harms evidence review folder.

In what may have been a coincidence of timing, on 30 September 2021 – the same day that the PHE evidence review was published – the newly appointed Gambling Minister Chris Philip MP visited the Leeds Gambling Addiction Clinic and met Dr Matthew Gaskell, following which he commented on Twitter: “His patients are almost all suicidal. We need to do a lot more to protect those who become, or are at risk of becoming, highly addicted or suffer crippling levels of losses”.


1. Regulus Partners have commented in their 3 October 2021 ‘Winning Post’ blog on the history of the evidence review, stating:

The project commenced in 2019 and was due to report back in the spring of 2020. It quickly became embroiled in controversy – the project leader imprudently signalling bias by claiming that “research and evidence are needed to support advocacy and action” and that it was necessary for researchers to “develop the narrative, through campaigns…to raise awareness” of gambling’s status as a “health harm”.

They consider there to be the following three “major flaws” in PHE’s estimate that gambling-related harms in England cost the economy around £1.2 billion a year :

  1. “the use of small sample studies from overseas jurisdictions to estimate prevalence of harm in England”,
  2. “the belief that apples and pears – or problem and pathological gambling – are basically the same thing (by definition, they are not)” and
  3. “PHE’s disregard for a well-established body of research on comorbidity and complex disorders”,

adding that:

  • “this allowed PHE to attribute 100% of the excess costs from problem gamblers to gambling – regardless of the involvement of other disorders or questions of precedence” and that whilst “the PHE cost estimates are necessarily over-stated …. they are demonstrably unreliable” and
  • “what is unclear is how on earth PHE was allowed to release such flawed estimates and what possessed the Department of Health and Social Care, the Department for Culture, Media and Sport and the Gambling Commission to endorse its findings. Where was the critical analysis? There is little point in the Government and its agencies commissioning research if they are unable to subject it to intelligent critical appraisal”.

It is inevitable that considerably conflicting arguments will be waged in coming months over the evidential weight that should be placed on PHE’s findings by Parliamentarians debating the forthcoming White Paper arising out of the Government’s Review of the Gambling Act 2005.

2. On 11 October 2021, the House of Lords Library published an ‘In-Focus’ paper entitled ‘Public Health England: Gambling-related harms review’ 

3. By way of a House of Lords debate on 14 October 2021 (a transcript of which may be read here), the Lord Bishop of St Albans (a vice-chair of ‘Peers for Gambling Reform’) asked the UK Government “what assessment they have made of the report by Public Health England Gambling-related harms evidence review, published on 30 September?”

The following speech in response was delivered by the Parliamentary Under-Secretary of State, Department for Digital, Culture, Media and Sport, Lord Parkinson of Whitley Bay:

My Lords, it has been a pleasure to listen to the debate this afternoon. I thank the right reverend Prelate the Bishop of St Albans for securing it. One of the first things I did when I joined your Lordships’ House was join the Select Committee on the Social and Economic Impact of the Gambling Industry, along with him, the noble Lord, Lord Foster of Bath, and my noble friends Lord Smith of Hindhead and Lord Mancroft. I am pleased to have the opportunity early on in my new role to debate this issue, which I know continues to interest a great number of people in your Lordships’ House.

Public Health England’s review is a valuable contribution to our understanding of gambling-related harm and the forms it can take. It is also especially timely. It was an important commitment made following the last gambling review in 2018, and I am happy to assure the right reverend Prelate that its findings will be carefully considered in the Government’s ongoing review of the Gambling Act.

The landscape of gambling, as in many areas of life, has changed significantly since 2005, but the objective of the Act to protect children and vulnerable people from being harmed or exploited remains fundamental to the Government’s vision for the sector. Our Gambling Act review will ensure that our regulatory framework is fit for the digital age. Its objectives include making sure that all those who choose to gamble in Great Britain can do so in a safe way.

The Gambling Commission’s work to strengthen protections is continuing alongside the review. As noble Lords noted, gambling is a leisure activity for most, but it is also clear that many people and their families have their lives devastated by gambling-related harm. The Government are clear that gambling harm is a public health issue, as a number of noble Lords rightly noted, and we treat it as such.

Gambling legislation and Gambling Commission regulation are designed to keep gambling safe for the population as a whole. However, we have more specific measures and targeted interventions to give appropriate protection to children and vulnerable adults. The report shows that the problem gambling rate among adults is 0.5% and has remained stable since 2012, but it is essential that those suffering harm receive the help they need. Our National Health Service has committed to opening 15 new treatment clinics for problem gamblers by 2024, and the industry has committed £100 million for treatment over the same period.

A number of noble Lords, including the right reverend Prelate and the noble Lord, Lord Foster, mentioned the costs of gambling harm. PHE reports found that the annual economic burden of harmful gambling is approximately £1.27 billion but, as my noble friend Lord Smith of Hindhead noted, the report makes it clear that the analysis presented estimates the costs associated with, not caused by, gambling. There are complicated interactions between gambling and mental health problems and, as the report makes clear, alcohol use. Nevertheless, the costs associated with gambling harm are stark, so there is clearly important work still to be done.

As the noble Lord, Lord Foster, said, the report identifies gaps in the evidence base. One of the aims of our review is to make sure that we have high-quality evidence to support regulation. We will work with the Department of Health and Social Care and key parties to address the knowledge gaps identified in the evidence review and improve data collection. He asked whether that would include data from companies. The Gambling Commission is taking forward work on a national data repository with the aim of collecting data for use by researchers; I am pleased to say that it will include data directly from gambling operators.

One area where there is an evidence gap, as was noted by the right reverend Prelate and the noble Baroness, Lady Merron, concerns regional disparities. He will not be surprised to know that my eye alighted on the fact that the north-east had the highest prevalence of at-risk gamblers. However, I also saw that the PHE report was clear that, because of the small numbers it studied, it was not possible to determine those levels with any statistical significance, so that is one area where further evidence is needed and further research needs to be undertaken.

A number of noble Lords including the noble Lord, Lord Sikka, and my noble friend Lord Smith mentioned children. I am pleased to say that children’s gambling participation is in decline. In 2011, 23% of 11 to 16 year-olds said that they had gambled in the past seven days, while in 2019 it was 11%. However, we cannot be complacent. This is why, as my noble friend Lord Smith alluded to, we have increased the minimum age limit to buy National Lottery products to 18. We are also considering other potential measures to protect children and young people as part of our review. If the noble Lord, Lord Sikka, would like to tell me about the website he mentioned, I would be glad to look into why he was able to get through and discuss that with him in further detail.

The noble Lord also talked about online protections more generally. Significant progress has been made in recent years to make online gambling safer, including a ban on gambling on credit cards and new rules to reduce the intensity of online slot games. However, we recognise that more can be done to protect those who gamble online. Our review is looking closely at the case for greater protections for online gamblers, including protections on products and for individuals. The Gambling Commission is also working to improve how operators use data to identify customers at risk of harm and intervene.

The noble Lord, Lord Sikka, asked about the tax arrangements of gambling operators. All companies selling gambling to customers in Great Britain pay UK gambling duties wherever they are based; the remote gaming duty is 21% of gross profit.

The noble Baroness, Lady Bennett of Manor Castle, and my noble friend Lord Robathan mentioned advertising. PHE’s evidence review did not find evidence that exposure to advertising and marketing is a risk factor for harmful gambling. However, operators must advertise responsibly. We are committed to tackling aggressive practices.

Lord Robathan (Con)
I should have congratulated my noble friend on his new post, by the way. If advertising does not encourage people to gamble, why are companies spending so much money on it?

Lord Parkinson of Whitley Bay (Con)
It is a competitive market and, if people choose to use their money in this way, operators are encouraging them to do it with their specific companies; as private enterprises, they are right to do that. But, as I say, operators must advertise responsibly and we are committed to tackling aggressive practices where we see them. We have called for evidence on advertising and sponsorship specifically as part of our review, and we are looking closely at the issue of sports sponsorship as part of it.

More broadly, on marketing and inducements, we have called for evidence on promotions and offers. One of the things I learned about when sitting on your Lordships’ committee was that the number of customers in VIP schemes has fallen by over 70% since the industry started following new rules on how the schemes should be run from September 2020. Gambling Commission and advertising rules already prohibit inducements which encourage customers to gamble more intensely, and operators are not allowed to market directly to those who have self-excluded or customers showing signs of vulnerability, but this is one of the areas we want to look into in the review.

The noble Baroness, Lady Bennett, asked about loot boxes. The Government are delivering on their manifesto commitment to tackle the issue of loot boxes in video games. We ran a call for evidence last year to understand their full impact and received over 30,000 responses. We are reviewing those responses and continuing to engage with the industry to determine the most robust and proportionate solutions, and our response will set out the next steps that we intend to take.

The noble Lord, Lord Foster, and others mentioned problem gambling in the Armed Forces. The Government are vigilant to the emergence of problem gambling among those serving in our Armed Forces, which includes providing welfare support and financial awareness training. The Ministry of Defence also blocks gambling websites on its networks to reduce their accessibility. PHE’s evidence review found no association between exposure to combat situations and problem gambling, and there is a lack of longitudinal evidence to clarify whether trauma is a risk factor for harmful gambling. However, we welcome further evidence in this area as well, and are taking a close interest in the results of a recent important study from Swansea University looking at gambling participation among ex-service personnel.

The right reverend Prelate mentioned the troubling estimate of over 400 gambling-related suicides per year in the PHE studies. Of course, any suicide is a tragedy. It is important to note that the figure in the PHE report is an estimate based on two overseas studies; we do not know how many suicides in the United Kingdom are linked to gambling. The Department of Health and Social Care is working to improve our data collection and address other evidence gaps on this most important of issues. NHS England is also investing £57 million in suicide prevention through the NHS long-term plan. Investment in all areas of England by 2023-24 will support suicide prevention plans locally and establish bereavement support services. We know how serious these impacts can be.

While the gambling review is ongoing, the Government and the Gambling Commission are not waiting for it to end to take action where it is needed to make gambling safer. In the last 18 months, we have: banned gambling on credit cards; tightened restrictions on VIP schemes; raised expectations of online operators during the Covid pandemic, with increased monitoring and intervention throughout; introduced new rules to limit the intensity of online slot games; and launched a consultation on new rules for customer interaction to protect people who gamble online. The Public Health England review is therefore a timely contribution to our ongoing efforts to prevent gambling harm. It will be considered very carefully as part of our thorough review of the Gambling Act, together with all the other evidence we continue to receive. We will publish a White Paper setting out any proposals for reform and our vision for the sector in the digital age in due course.

I give my thanks again to the right reverend Prelate and all noble Lords who have spoken in today’s debate. I know they will continue to contribute to the debate in this important area.

4. In their 14 November 2021 ‘Winning Post’ blog, Regulus Partners reported that:

A Public Health England research team (now part of the Office for Health Improvement and Disparities) admitted that it had ignored the economic and social benefits of gambling in its recent review because it considered that an exclusive focus on costs would attract greater attention from the Government.

adding comment that:

This is undoubtedly true but is an effective admission that PHE’s remit was a lobbying one – something that may help to explain the shoddiness of its approach to cost estimation. PHE researchers also claimed that they were only interested in those harmed by gambling and that such people were unlikely to experience any benefits. This may be largely true where disordered gamblers are concerned but is unlikely to be the case for ‘low risk’ gamblers, most of whom do nothing more egregious than occasionally attempting to win back money lost.

5. On 12 July 2022, an iGaming Business article entitled ‘The flaw in the Public Health evidence base’ (written by Scott Longley at a time when it was anticipated that publication of the Gambling Act Review White Paper was extremely imminent) summarised the bases on which the PHE evidence is flawed, in the process expressing the opinion that:

Without the evidence to back up the numbers, it suggests the government will be basing the White Paper proposals on the evidence of a report that is both opaque in terms of its calculations and cannot be used to causatively assess the involvement of gambling in those harms.

Download article PDF: Gambling_risk_factors
Download article PDF: Gambling_review_COVID_report