By Associate Professor Charles Livingstone, School of Public Health & Preventive Medicine, Monash University
State governments are planning to reopen pokie venues due to heavy lobbying by the gambling industry. However, there a number of public health issues which need to be addressed to ensure reopening these venues will not endanger the health of those who use or work there.
Australia’s 194,000 pokies or electronic gambling machines (EGMs) are mainly located in hotels and clubs, and in casinos. These venues also provide other forms of gambling, including Keno, wagering (often using terminals to place bets) and, in casinos, table games. All these gambling venues have been closed during the restrictions arising from the COVID-19 pandemic.
Before these venues are reopened many changes will be needed to reduce the risk of infection. These were not particularly healthy environments even before COVID came along. There needs to be careful consideration and enforcement of modifications to the layout of premises, gaming machine spaces, cleaning of machines, and other operating practices..
But there are wider public health issues to address, dealing with the personal impact of gambling, stress and mental health, and income loss and social inequalities that in turn drive other forms of ill health.
Key to addressing these issues is awareness of the well-established relationship between social disadvantage and stress, and poor physical and mental health outcomes. Australia has very high concentrations of EGMs and they are regressively located. It is also likely that suicide rates could increase significantly as a result of the economic and other consequences of the pandemic. However, links between gambling, disadvantage, and mental health are less well comprehended.
Transmission of infectious disease
As part of comprehensive measures to prevent infectious diseases spreading, it is essential that gambling venues reopen only when all changes to physical layout and cleaning procedures are fully implemented, in accordance with the best advice from qualified public health experts, and with the approval of State and Commonwealth Chief Medical or Health Officers. This includes arrangements for physical distancing, calculation and effective enforcement of a maximum occupant capacity for each gambling room to be opened, and cleaning procedures for EGMs or other equipment utilised for gambling activities (chips, cards, wagering terminals, terminals for keno or automated table games, etc.). It may also be desirable to impose ‘session limits’ on patrons to limit time spent in specific gambling rooms and thus reduce likelihood of transmission of pathogens.
The health and safety of staff is also of paramount concern, both for their own protection and to avoid the transmission of disease to others. All necessary measures should be taken to ensure this, including the supply and use of personal protective equipment where required. Again, such arrangements and procedures must be subject to approval by State and Commonwealth Chief Medical or Health Officers and their delegates.
Mental health issues
There is a well-established link between the incidence of mental health conditions and the use of EGMs and other forms of gambling. Habitual or addictive use of EGMs exacerbates existing mental health issues, and may also result in the onset of some mental health conditions.
The COVID-19 pandemic and associated restrictions, has significantly increased the incidence of mental health conditions. Loss of employment and financial difficulties will cause significant stress and anxiety for many. People with established habitual or addictive gambling behaviours have been constrained from using many forms of terrestrial gambling for some time. Some may have migrated to, or increased, online gambling activity. However, it appears that this has not substituted for more than a fraction of terrestrial gambling activity. For example, online gambling activity appears to have increased by about two-thirds (equivalent to $2 billion p.a.). EGM gambling accounts for $15 billion in losses p.a.
As with other addictive products, some people with mental health issues use gambling to ‘self-medicate’, as it appears to stimulate release of neurochemicals that provide temporary relief of some symptoms. However, the costs of gambling (particularly EGM gambling) are prohibitive, and any relief is both short-lived and likely to exacerbate existing disorders.
It is important therefore, that when EGM and other gambling venues reopen consideration is given to the likelihood that a significant number of gamblers will be drawn to gamble in order to relieve symptoms of anxiety and stress. This may include some who have been ‘casual’ gamblers in the past. If EGMs are used by people in this situation, there is a strong likelihood they will develop habitual or addictive gambling behaviour.
There is also a strong likelihood that gamblers with mental health conditions who have modified their gambling behaviour during the COVID-19 restrictions will relapse in response to the availability of EGMs or other gambling, and to escape temporarily from the anxiety and stress of the current situation.
Disadvantage and stress
EGM venues are disproportionately located in areas of social disadvantage and stress. This is because such locations are highly lucrative for gambling operators. In some Australian states, very large and highly lucrative EGM venues are located in the most disadvantaged suburbs and towns (e.g., Fairfield in Sydney, or Dandenong in Melbourne).
The impact of the COVID-19 restrictions on the social distribution of disadvantage and income is not yet clear. It is unlikely to be evenly distributed across society, and there is a likelihood that already disadvantaged workers will be further disadvantaged by job losses and business closures. The stress and heightened disadvantage will induce a proportion of those affected to engage in risky behaviour, including gambling, in order to either (mistakenly) seek to improve their financial position, or to relieve stress and anxiety. People who have no or reduced income as a result of the loss of casual employment, for example, will be disproportionately affected.
The potential for gambling to greatly exacerbate disadvantage and stress in already disadvantaged communities is greatly heightened by this continuing situation.
COVID-19 restrictions appear to have led to increased demand for family violence services. This is a major risk factor for men’s, women’s and children’s health increasing stress and anxiety, which in turn is a risk factor for gambling disorders. The relative density of EGMs in local areas is also a risk factor for family violence. Access to EGM venues in the current economically difficult situation is likely to lead to further increased rates of family violence.
What can ameliorate this situation?
Gambling harms many people. Most gambling revenue, for example, comes from people with significant or major gambling disorders. EGM venues in particular are located in areas of social disadvantage and stress.
There is a significant likelihood that reopening gambling venues will make the current difficult situation worse for many people. Most likely to be affected will be already experiencing significant disadvantage, stress, and associated impaired health and wellbeing.
For these people, their dependents and friends, employers and neighbours, existing impacts of the COVID-19 pandemic will be greatly heightened. This in turn will lead to increased rates of illness, suicide, and significant detrimental economic impacts across affected communities.
State governments, advised by public health authorities, have a responsibility to be diligent in addressing very real risks of both COVID-19 and other health and social harms that will result from the re-opening of electronic gambling venues.