KISS: Gambling

NICE NG248 Jan 2025

Background:

• Multiple factors, including liberalisation of gambling laws, easy access to online gambling with aggressive and persistent advertising and marketing, has created ‘an environment in which gambling that harms is an increasing problem’.
• On top of this, gambling has been normalised in society to be perceived as an ‘acceptable and harmless leisure pursuit’, so stigma around harmful gambling is particularly high (compared to drug and alcohol addiction) driving additional barriers to recognising, accepting and seeking help for harmful gambling.
• The Gambling Survey for Great Britain 2023 found that:
  • 2.5% of >18s participate in problem (high risk of harm) gambling; a further 12% gamble with an elevated risk of harm.
  • Rates of gambling are highest in men and younger adults (aged 18-34 years).
  • Of those who had gambled in the last 12 months:
    • 2.8% reported ≥1 severe consequence, with relationship breakdown being the most cited consequence.
    • 11.4% reported thoughts or attempts to end their life.
• It is estimated that 7% of the population are personally affected by other's gambling. 
• Gambling affects individuals (with higher burdens of physical and mental health problems and suicide risk), family and friends (including domestic violence, family breakdown, child neglect, homelessness) and wider society (criminal activity and burdens on mental health, housing and criminal justice systems) with an estimated annual cost of ~£1-1.75 billion.
• Access to treatment is limited - this guideline aims to heighten awareness of the scale of the problem and improve access to gambling services, in part from investment from the new statutory levy on gambling operators. 
• Although aspirational in parts with sections directed at commissioners and service providers, this guideline has important information for Primary Care in terms of how we should identify problem gambling and has helpful, practical guidance on how to reduce harms from problem gambling as well as signposting to further support.
• The guidance highlights the importance of information and support being ‘unbiased’ due to the known issue about ‘the influence of the gambling industry on information provided to people experiencing gambling-related harms’.

How can we identify problem gambling in General Practice?

• Recognise/be aware of the stigma, shame and fear of disclosure about gambling, particularly in people from marginalised, minority or under-represented groups.
• Ask about gambling in the following situations:
  • As part of holistic health checks or new registrations at GP practices.
  • Any mental health presentation, including depression/anxiety/bipolar/PTSD/ADHD, and especially if any thoughts of self-harm or suicide.
  • Any situation associated with drug/alcohol misuse/dependence (particularly cocaine use).
  • If at risk of or experiencing homelessness.
  • If any financial concerns are disclosed.
  • Safeguarding, violence or domestic abuse.
• Be particularly aware of high risk groups: 
  • Neurological conditions or brain injury that leads to disinhibition or increased impulsivity. 
  • Young people recently leaving home. 
  • Armed forces personnel or veterans.
  • Those working in professional sports, financial industries or gambling industries. 
• Also, be aware of gambling risks in those with Parkinson's Disease taking dopamine agonists (e.g. pramipexole, ropinirole) due to the increased risk of impulse control disorder, as well as in those on aripiprazole for psychosis.
• ASK DIRECT QUESTIONS PROACTIVELY e.g. ‘Do you gamble?’; NB comment this should start being a default question in the same way we routinely ask about smoking, alcohol and drug use.

What next? Risk assess:

• If we or the person are concerned about their gambling direct them to the NHS website questionnaire to risk assess:
  • Do you bet more than you can afford to lose?
  • Do you need to gamble with larger amounts of money to get the same feeling?
  • Have you tried to win back money you have lost (chasing losses)?
  • Have you borrowed money or sold anything to get money to gamble?
  • Have you wondered whether you have a problem with gambling?
  • Has your gambling caused you any health problems, including feelings of stress or anxiety?
  • Have other people criticised your betting or told you that you had a problem with gambling (regardless of whether or not you thought it was true)?
  • Has your gambling caused any financial problems for you or your household?
  • Have you ever felt guilty about the way you gamble or what happens when you gamble?
    • Scoring: 0 = “never”; 1 = “sometimes”; 2 = "most of the time"; 3  = "almost always"
    • Total score 8 or higher, you or those closest to you, are likely to be experiencing gambling-related harms.
    • Total score between 1 and 7, gambling might still be having a negative impact on your life.
• This questionnaire is based on the Problem Gambling Severity Index (PGSI):
  • PGSI = 0 = 'Non-problem gamblers’ 
  • PGSI = 1-2 = ‘Low Risk’ (low level of gambling problems with few or no negative consequences identified)
  • PGSI = 3-7 = ‘Moderate risk’ (moderate level of gambling problems leading to some negative consequences)
  • PGSI = ≥8 = ‘Problem gamblers’ (gambling with negative consequences and a possible lack of control)
  • As with all questionnaires there are caveats around the context of use, the difference between ‘probability and impact’, thresholds (particularly in the ‘at risk’ scores) and interpretation of risk (e.g. those in ‘low risk’ may already be experiencing harm from their gambling, yet there is no inevitability that those in ‘at risk’ groups will go on to develop problem gambling).

How can we support people with problem gambling?

• Be supportive that treatments are available and recovery is possible.
• Use a person-centred, empathic and non-judgemental approach, and be mindful/open about the shame, fear and stigma that may be present when disclosing gambling harms.
• Signpost to the NHS website on gambling problems (and other support services - see below)
• Consider brief motivational interviewing to encourage them to seek further help and support.
• Recognise the suicide risk - assess directly about this and manage as usual, including safety plans.
• If related to iatrogenic drug causes e.g. PD dopamine agonists, discuss with relevant specialists to ↓medication doses. 
• Discuss practical techniques to prevent gambling, including (see also support below):
  • Blocking software or tools to prevent online gambling.
  • Blocking marketing messages.
  • Self-exclusion systems for land-based gambling such as casinos, arcades and betting shops.
  • Systems that block gambling payments through the person's bank account.
  • Methods to limit access to money, for example, agreeing that a family member will take control of finances.
• Direct to services that can help gambling-related harms e.g. mental health services, debt advice, financial advice etc.
• Remember to direct affected others (family/friends affected by others gambling) to support services too.
• Further treatments should (ideally) be directed by the specialist services/clinics but some principles to be aware of:
  • Unbiased information should be provided, including discussions/insights into the nature of how the gambling industry incentivises and encourages problem gambling which is designed to tap into the reward systems in the brain.
  • For most the aims of treatment are abstinence.
  • Psychological interventions should include motivational interviewing and CBT (group or individual).
  • Pharmacological interventions include naltrexone.

Gambling Support Services:

• NHS Support services - Help for problems with gambling, including a self-assessment questionnaire.
  • This includes a section on how to access gambling clinics via self-referral depending on where you live.
• GamLearn - Lived experience and recovery network.
• Gamblers Anonymous - local support using the 12-step programme.
• GambleAware - the National Gambling Support Network service.
• Primary Care Gambling Service - a national service providing support for anyone experiencing gambling-related harms.
• GamStop and Gamban - online blocking/restriction service.
• GamCare - comprehensive support and self-guided resources and CBT are available online and with support. (NB - for info, GamCare is funded by GambleAware, which is funded by a voluntary levy from the gambling industry).
• ChapterOne - a charity that can provide advice and support for anyone experiencing gambling-related harms