www.thelancet.com/public-health Vol 9 November 2024 e950 The Lancet Public Health Commissions Lancet Public Health 2024; 9: e950–94 Published Online October 24, 2024 https://doi.org/10.1016/ S2468-2667(24)00167-1 *Commission Co-Chairs School of Social and Political Sciences, University of Glasgow, Glasgow, UK (Prof H Wardle PhD, Prof G Reith PhD, B Biggar PhD, Prof C Bunn PhD, V Kesaite PhD, D Ukhova PhD); National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia (Prof L Degenhardt PhD, L T Tran MSc, Prof M Farrell PhD); Centre for Research on Addiction, Control and Governance, University of Helsinki, Helsinki, Finland (V Marionneau PhD); School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia (C Livingstone PhD, A Rintoul PhD); Harvard Kennedy School (Prof M Sparrow PhD) and Department of Global Health and Population, Harvard TH Chan School of Public Health (Prof S Saxena MD), Harvard University, Cambridge, MA, USA; Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Prof C Bunn); Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK (V Kesaite); Alcohol, Drugs and Addictive Behaviours Unit, WHO, Geneva, Switzerland (V Poznyak MD); School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China (J Quan MD); Institute for Mental Health Policy Research (Prof J Rehm PhD) and Campbell Family Mental Health Research Institute (Prof J Rehm), Centre for Addiction and Mental Health, Toronto, ON, Canada; Dalla Lana School of Public Health (Prof J Rehm) and Department of Psychiatry (Prof J Rehm), University of Toronto, Toronto, ON, Canada; The Lancet Public Health Commission on gambling Heather Wardle*, Louisa Degenhardt*, Virve Marionneau, Gerda Reith, Charles Livingstone, Malcolm Sparrow, Lucy T Tran, Blair Biggar, Christopher Bunn, Michael Farrell, Viktorija Kesaite, Vladimir Poznyak, Jianchao Quan, Jürgen Rehm, Angela Rintoul, Manoj Sharma, Jeremy Shiffman, Kristiana Siste, Daria Ukhova, Rachel Volberg, Joana Salifu Yendork, Shekhar Saxena* Executive summary The global gambling industry The global gambling industry is rapidly expanding, with net losses by consumers projected to reach nearly US$700 billion by 2028. Industry growth is fuelled by the rise of online gambling, widespread accessibility of gambling opportunities through mobile phones, increased legalisation, and the introduction of commer- cial gambling to new areas. Recent expansion is most notable in low-income and middle-income countries, where regulatory infrastructure is often weak. Gambling, in some form at least, is now legally permitted in more than 80% of countries worldwide. Online gambling, given its borderless accessibility, is available everywhere via the internet. Digitalisation has transformed the production and operation of commercial gambling, but the consequences of this shift and its effects on consumers have not yet been fully recognised. The production of online gambling is interconnected with an ecosystem of software, information technology infrastructure, and financial technology services. The commercial gambling industry has also developed strong partnerships in media and social media. Sponsoring and partnering with profes- sional sports organisations provides gambling operators with marketing opportunities with huge new audiences. This far-reaching and interdependent corporate ecosystem collectively wields substantial influence over policy and has multiple points-of-contact through which to leverage the behaviour of consumers. Online gambling products are designed to be rapid and intensive, characteristics that are associated with higher risk of harm for consumers. The introduction of in-game betting during live matches has made online sports betting instantaneous and increased both its frequency and prevalence. Traditional gambling products, such as lotteries and bingo, now have faster cycles and are con- tinuously accessible through smartphone apps. The boundaries between digital gaming and gambling are becoming blurred, with gaming increasingly acting as a conduit into gambling. Leveraging online digital infrastructures and surveil- lance data, gambling companies now have unparalleled capabilities to target consumers, including through the use of social media and influencers to engage individuals and online user data to tailor marketing to individuals, cross-sell products, and prolong user engagement. To safeguard their interests, stakeholders in the com- mercial gambling ecosystem deploy a range of strategies, many of which are similar to those used by other indus- tries selling potentially addictive or health harming products. To shape public and policy perceptions, and as they lobby policy makers directly to further their com- mercial interests, the industry portrays gambling as harmless entertainment and stresses the economic benefits (including tax revenues) and employment opportunities that the industry provides. The gambling industry particularly stresses the social benefits that accrue when some portion of gambling profits are used to fund education, health services, or other worthwhile social causes. According to industry narratives, responsi- bility for gambling harm is attributed to individuals, particularly those deemed as engaging in problematic gambling, which deflects attention from corporate conduct. The gambling industry also exerts considerable influence over research into gambling and gambling harms, which helps it to retain control of the framing and messaging surrounding these issues. Industry messaging has substantially influenced gambling policy and regulation. Most policy solutions to gambling harms rest on the notion of individual respon- sibility. Providing support services, treatments, and protections for at-risk individuals is, of course, important. Improving these remedies further and making protective supports broadly available remains a priority. However, framing the problem in this way and narrowly focusing policy attention on a small subset of the people who gamble draws attention away from industry practices and Key messages • Commercial gambling is a rapidly growing global industry and is becoming increasingly digital. • The harms to health and wellbeing that result from gambling are more substantial than previously understood, extending beyond gambling disorder to include a wide range of gambling harms, which affect many people in addition to individuals who gamble. • Evolution of the gambling industry is at a crucial juncture; decisive action now can prevent or mitigate widespread harm to population health and wellbeing in the future. Thus far, globally, governments have paid too little attention to gambling harms and have not done enough to prevent or mitigate them. • Stronger policy and regulatory controls focused on harm prevention and the protection of public health and wellbeing, and independent of industry or other competing influences, are now needed. Given the increasingly global and boundary-spanning nature of the industry, international coordination on regulatory approaches will be necessary. http://crossmark.crossref.org/dialog/?doi=10.1016/S2468-2667(24)00167-1&domain=pdf e951 www.thelancet.com/public-health Vol 9 November 2024 The Lancet Public Health Commissions Center for Interdisciplinary Addiction Research, University Medical Center Hamburg– Eppendorf, Hamburg, Germany (Prof J Rehm); Health Innovation and Transformation Centre, Federation University, Churchill, VIC, Australia (A Rintoul); Centre for Mental Health and Community Wellbeing, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia (A Rintoul); Department of Clinical Psychology, Govindaswamy Centre, National Institute of Mental Health and Neuro Sciences, Bengaluru, India (Prof M Sharma PhD); School of Advanced International Studies, Bloomberg School of Public Health, John Hopkins University, Baltimore, MD, USA (Prof J Shiffman PhD); Department of Psychiatry, Faculty of Medicine, Universitas Indonesia–Dr Cipto Mangunkusumo General Hospital, Jakarta, Indonesia (K Siste PhD); School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA (Prof R Volberg PhD); Department of Psychology, University of Ghana, Accra, Ghana (J Salifu Yendork PhD) Correspondence to: Prof Heather Wardle, School of Social and Political Sciences, University of Glasgow, Glasgow G12 8RT, UK heather.wardle@glasgow.ac.uk corporate behaviour. We must also seriously examine the structures and systems that govern the design, provision, and promotion of gambling products. Gambling harms Gambling can inflict substantial harm on individuals, families, and communities. Beyond the obvious danger of financial losses and financial ruin, these harms can include loss of employment, broken relationships, health effects, and crime-related impacts. Gambling can heighten the risk of suicidality and domestic violence. Research evidence and firsthand accounts from individu- als affected by gambling corroborate the association between gambling and these many and various detri- mental effects. A substantial proportion of harm is suffered by those individuals who fall below the threshold for gambling disorders outlined in the International Classification of Diseases-11 or the American Psychiatric Association’s Diagnostic and Statistics Manual-5. Therefore, examining the effect of gambling across the entire spectrum of con- sumption is crucial. As with other harmful commodities, adverse effects are often felt not just by the person gambling, but also by significant others, families, and friends, and can result in both tangible and intangible costs to communities and societies. Although some harms might be short-lived, others are long lasting and can affect subsequent generations. This Commission conducted a systematic review and meta-analysis of the global prevalence of gambling par- ticipation, including any risk gambling (defined as occasional experience of at least one behavioural symptom or adverse consequence from gambling), gambling disorder, and problematic gambling in adults and adolescents. We estimate that 46·2% of adults and 17·9% of adolescents had engaged in gambling of some form within the preceding year, globally. 10·3% of the adolescents had gambled online, which is noteworthy given the widespread agreement that commercial gambling among adolescents should be prohibited. Approximately 5·5% of women and 11·9% of men expe- rience any risk gambling. Extrapolating these findings globally would suggest that approximately 448·7 million adults worldwide could be similarly affected. Of these, an estimated 80 million adults experience gambling disorder or problematic gambling. Moreover, we estimate that gambling disorder could affect 15·8% of the adults and 26·4% of the adolescents who gamble using online casino or slot products, and 8·9% of the adults and 16·3% of the adolescents who gamble using sports betting products. These findings underscore the potential harmfulness of products (eg, online casino or slot games and sports betting) that are now driving the global expansion of the gambling industry. Our systematic review also uncovered substantial defi- ciencies in the global monitoring of gambling harms. Monitoring has relied primarily on population surveys, despite recognised methodological issues with these approaches, which are likely to produce conservative estimates. Moreover, in many countries, even general population surveys are unavailable. Consequently, the evidence base remains fragmented and clearly incom- plete given the global scale of the issue. Policy response and regulation This Commission stresses that gambling is a public health issue. A public health approach to regulating the gambling industry and preventing and responding to related harms should underpin policy design, implemen- tation, and review. The Commission assessed the gambling policy process by scrutinising policy framing, adoption, and enforcement, acknowledging the impor- tance of each stage in influencing public health outcomes. Policy framing, also known as agenda setting, has a crucial role in shaping policy objectives. The Commission conducted an empirical study examining the global framing of new gambling legislation from 2018 to 2023 across 80 jurisdictions. New legislation during this period mainly focused on legalising online gambling. The most common rationales for changes in gambling legislation included transparency and integrity of gambling products, economic growth, and crime pre- vention. Although a third of jurisdictions cited some health-related rationales, these often focused specifically on prevention of gambling addiction or gambling disorder, rather than broad public health protections. Regional variations in regulatory motivation were evident, with economic rationales being more prevalent in North America, whereas public health rationales were more common in Europe. Many legislative texts incorpo- rated competing rationales, with health juxtaposed with economic considerations. The resulting tension between competing policy priorities manifests throughout the policy cycle. Effective policy tools exist to prevent the broad range of harms associated with gambling. Evidence indicates that universal measures targeting entire populations are the most effective when implemented consistently and com- prehensively, aligning with a public health approach. Measures with increased effectiveness include enforcing legal age limits, restricting gambling availability and accessibility, prohibiting or substantially limiting adver- tising, implementing universal and mandatory limits for gambling consumption, and placing controls on gambling product characteristics known to be harmful. In addition to such population-level measures, selective and targeted interventions are necessary to support indi- viduals who are at risk of gambling harms, or who are already experiencing or recovering from them. These measures encompass self-exclusion policies, personal- ised messaging and feedback on gambling consumption, interventions based on tracking data, and therapeutic services. This Commission views both classes of www.thelancet.com/public-health Vol 9 November 2024 e952 The Lancet Public Health Commissions interventions—population level and individual level—as essential, but argues that it is the population-level, public- health interventions that have had insufficient attention from policy makers, have lagged behind other measures in terms of design and implementation, and which now need special emphasis. Even where jurisdictions have prioritised public health concerns in their policy framing, effective population- level measures remain inconsistently implemented. Regulation of gambling harms still revolves primarily around the so-called responsible gambling paradigm, which keeps the focus on individuals deemed to be gambling problematically and diverts attention away from the nature and conduct of the commercial gambling ecosystem. Policy framing also influences the choice of regulatory priorities and the regulatory structures used to deliver them. Available regulatory structures include rules-based (prescriptive) regulation and self-regulatory practices. Although rules-based standards are common in areas such as gambling product integrity, taxation, and crime prevention, the control of gambling harms has relied on a mixture of prescriptive and self-regulatory approaches. Self-regulatory approaches work best when public and private commercial interests are closely aligned, whereby private motivations are sufficient to serve public interests. With respect to the control of gambling harms—which, if effective, would reduce corporate profits to some degree—the assumption of alignment is fundamentally unreliable. Regulating an increasingly global gambling industry presents substantial challenges, but they are not insur- mountable. The global nature of the industry necessitates strong international regulatory collaboration. Additionally, increased levels of research and improved monitoring systems are required to produce credible, independent, non-industry-driven, and therefore reliable, evidence on gambling harms and the efficacy of various control methods. Without adequate oversight, profit-driven corporate behaviours in the gambling industry will pose ever greater risks to a widening circle of consumers and to public health worldwide. Recommendations The Lancet Public Health Commission on gambling convened a multidisciplinary group of experts in gambling studies, public health, global health policy, risk control, and regulatory policy; along with contributors who have firsthand experience of gambling harms. Our conclusion is clear: gambling poses a threat to public health, the control of which requires a substantial expansion and tightening of gambling industry regula- tion. Timely response to this growing worldwide threat necessitates concerted action at intergovernmental, national, and regional government levels. Our full rec- ommendations are shown in panel 1. Introduction “No matter how you think you can outsmart the thing, they always win. Even if you think you’ve won some money, they’ve still won…” Male sports bettor, aged 19 years Gambling transformation and commercialisation The worldwide expansion of the gambling industry has been propelled by technological advancements that lie at the core of the so-called digital revolution.1,2 Digital and mobile technologies integrated into gambling products result in more immersive and portable games and broader availability to vast global audiences, traversing previous physical barriers. Traditional gambling products, such as casino games and slot machines, have been digitised and made available online. Simultaneously, the almost ubiquitous availability of mobile phones, as a means to access the internet, has contributed to the surge in online gambling availability, creating a so-called casino in your pocket 24/7.3,4 Many lotteries can now be Panel 1: Key recommendations 1 Gambling is a public health issue; in setting policy, governments should prioritise protecting health and wellbeing over competing economic motivations. 2 In all countries—irrespective of whether gambling is legally permitted—effective gambling regulation is needed; we recommend: • Reductions in population exposure and the availability of gambling, through prohibitions or restrictions on access, promotion, marketing, and sponsorship. • Provision of affordable, universal support and treatment for gambling harms. • De-normalisation of gambling via well resourced social marketing and awareness campaigns. 3 Jurisdictions that permit gambling need a well resourced, independent, and adequately empowered regulator, focused on the protection of public health and wellbeing; at a minimum, regulatory protections must include: • Protection of children and adolescents from gambling, by enforcing minimum age requirements, backed by mandatory identification. • Provision of effective consumer protection measures, such as universal self-exclusion, and user registration systems. • Regulation of products proportionate to the risk of harms, based on their characteristics. • Enaction of mandatory measures limiting gambling consumption, such as enforceable deposit and bet limits, and universal precommitment systems. 4 Gambling-related policy, regulation, treatment, and research must be protected from the distortionary effects of commercial influence; we advocate for a rapid transition away from industry-funded research and treatment, coupled with and enabled by increased levels of investment from independent sources. 5 At the international level, UN entities and intergovernmental organisations should incorporate a focus on gambling harms into their strategies and workplans for improving health and wellbeing broadly. 6 There is a need to develop an international alliance—including civil society, people with lived experience of harms related to gambling, researchers, and professional organisations—to provide thought leadership, advocacy, and convening of interested parties. 7 This Commission recommends the instigation of the process to adopt a World Health Assembly resolution on the public health dimensions of gambling. e953 www.thelancet.com/public-health Vol 9 November 2024 The Lancet Public Health Commissions played continuously via a smartphone app, which is a radical departure from their traditional format (ie, the weekly purchase of a physical ticket). Developments, such as in-play betting, allow wagering not only on the outcome of sporting contests, but also on multiple moments throughout a match. Sports betting thus acquires a rapid and continuous format. Digitisation has enabled the emergence of expansive international gambling markets.5 Online gambling is the fastest growing sector of the industry, with estimates that the gross online gambling yield (the amount lost by consumers) will grow to US$205 billion by 2030;6 gambling yield for all forms of commercial gambling is projected to grow to nearly $700 billion by 2028.7 Many global commercial gambling companies exist as digital- only entities. Other gambling operators adopt digital-first business models as they aim to integrate both land-based and online offerings. Responding to the vast supply-side competition inherent in the online market, businesses and brands have consolidated, forming large, powerful groups. Simultaneously, gambling companies have directed their attention towards innovative marketing approaches rooted in data surveillance. Gambling applications allow direct and real-time communication between gambling operators and consumers. Operators use consumer data to profile behaviours and personalise marketing offers. Partnerships with other commercial entities broaden the reach of the gambling industry, allowing it to contact or influence consumers through sporting arenas and social media platforms. Digital expansion has increased the gambling industry’s geographical reach, notably into low-income and middle-income countries (LMICs), many of which have little previous exposure to commercial forms of gambling activity (eg, expansion into countries in sub- Saharan Africa8). Digital transformation of gambling poses novel challenges, such as penetration of offshore- based gambling operations into countries where all forms of gambling are banned. In Indonesia, for example, commercial gambling is illegal, but online gambling products are readily available to the public. The distinction between gaming and gambling has also been blurred. Gambling features have now been incorporated into online games, further exposing children and adolescents to gambling and gambling-like activities.9 The growth of the gambling industry can be viewed from several different perspectives. From an economic perspective, this growth represents increased commer- cial activity and additional employment opportunities in the industry. Commercial firms satisfy their fiduciary obligations to generate returns for shareholders by max- imising profits. From a revenue perspective, gambling also provides means for governments (national, state, or local) to generate income, most commonly by operating lotteries. Proceeds can be used to supplement general tax revenues or can be earmarked for specific social purposes. The Commission, however, seeks to emphasise and elevate the public health perspective on gambling by focusing on harms resulting from gambling activities. These harms include financial losses, health conse- quences, both physical and mental, and impacts on wellbeing, equity, social justice, and crime. Harms affect not only those who gamble, but also their families, friends, and communities. In adopting a public health perspective, we focus on the protection of populations from gambling harms. Historically, economic and financial perspectives have heavily influenced policy discussions, taking priority over considerations of public health protection. This Commission now seeks to redress this balance, at what is an important moment in the evolution of the gambling industry. Gambling harms and public health Commercial gambling is associated with a range of harmful effects for individuals, families, communities, and societies.10 Gambling increases risks of suicide and domestic violence11–13 and is associated with financial destitution and family rupture, which can have long-last- ing consequences for individuals and their families.14 These harms might last lifetimes and have consequences that span generations. Gambling disorder (panel 2) is a recognised health disorder and is classified both within the International Classification of Diseases-11 (ICD-11)16 and the American Psychiatric Association’s Diagnostic and Statistics Manual-5 (DSM-5)17 as a disorder due to addictive behav- iours. Epidemiological studies have focused primarily on measuring rates of disordered gambling, which are expressed as percentages of the total population (including those individuals who do not gamble). Estimates for rates of disordered gambling vary across regional studies, from 0·1% to 5·8% of the relevant pop- ulations.20 However, harms are experienced across the entire spectrum of consumption, affecting many other individuals who gamble, but would not be classified as having disordered gambling. The ICD-1116 additionally identifies so-called hazardous gambling as: “a pattern of gambling that appreciably increases the risk of harmful physical or mental health consequences to the individual or to others around the individual”. Hazardous gambling describes patterns of gambling behaviour that warrant “attention and advice from health professionals but does not meet the diagnostic requirements for gambling disorder”. International guidelines indicate that individuals who gamble more than four times a month or engage in more than two different types of gambling activities are subject to substantially heightened risks of gambling harms.21 The global prevalence of hazardous or harmful gambling is unknown. However, harm from gambling is www.thelancet.com/public-health Vol 9 November 2024 e954 The Lancet Public Health Commissions experienced not just by those classified as suffering gambling disorder. The proportion of the overall popula- tion affected by harmful gambling will be higher still when considering the effect on families, friends, and relatives of those who gamble.22 Thus, the true scale and scope of harms generated by gambling remain uncertain, though the actual scale exceeds currently available estimates. Specific groups face an elevated risk of gambling harms. These include children and young people, now routinely exposed to gambling product advertising and industry messaging and sponsorship, in ways that were unprecedented before the digital revolution.23 Exposure to industry messaging and product advertising influ- ences young people’s propensity to gamble and normalises gambling within their peer groups.24 The effect is especially potent among sports fans.24,25 Moreover, the distribution of gambling harms is not equal across society. Some gambling products draw a sub- stantial proportion of overall revenues from those least able to afford their losses—ie, from socioeconomically disadvantaged individuals who have an increased likeli- hood of suffering harm due to financial losses.26–28 Governments supporting the expansion of commercial gambling rarely acknowledge the potentially regressive inequities in the generation of gambling revenues, and tend to overlook how the growth of gambling might exacerbate social inequity by generating corporate profits at the expense of individuals most likely to experience harm. Panel 2: Key terms and language Gambling: the staking or risking of money or something of material value on an event that has an uncertain outcome in the hope of winning additional money or material goods.15 Commercial gambling: the commercial provision of gambling by companies and entities established to provide these products at scale for profit. The commercial gambling sector might be supported by governments through systems of licensing or governments themselves might be providers of commercial gambling through monopoly arrangements. Profits might be retained by the company or redistributed for social causes. Commercial companies can operate in settings where there is no regulation, where there is little oversight, or as illegal operators where prohibitions exist. Gambling products: includes a diverse range of products, including lotteries and related products (eg, scratch cards), betting, bingo, electronic gambling machines, and casino table games, all of which are offered in a range of contexts and across a range of formats, including online and mobile provision. Gambling harms: the adverse effects from gambling on the health and wellbeing of individuals, families, communities, and society. Hazardous gambling: term used in the International Classification of Diseases-1116 (ICD-11) to describe a pattern of gambling that appreciably increases the risk of harmful physical or mental health consequences to the individual who gambles, or to others around the individual, which might require intervention or monitoring, but which is not considered a disorder. Gambling disorder: a recognised disorder in the two major classifications of mental and behavioural disorders—the ICD-11 and the American Psychiatric Association’s Diagnostic and Statistics Manual-5 (DSM-5).17 The DSM-5 states that gambling disorder is identified by a pattern of repeated and ongoing betting and wagering that continues despite creating multiple problems in several areas of an individual’s life. The ICD-11 states that gambling disorder is characterised by a pattern of persistent or recurrent gambling behaviour, manifested by impaired control over gambling (eg, onset, frequency, intensity, duration, termination, context), increasing priority given to gambling to the extent that gambling takes precedence over other life interests and daily activities, and continuation or escalation of gambling despite the occurrence of negative consequences. The pattern of gambling behaviour might be continuous or episodic and recurrent. The pattern of gambling behaviour results in substantial distress or impairments to personal, familial, social, educational, occupational, or other important areas of functioning. Problem or problematic gambling: a commonly used term to describe gambling practices that create multiple problems that disrupt personal, family, financial, and employment circumstances; this term is sometimes used interchangeably with gambling disorder. Any risk gambling: this term is used to include individuals who meet the thresholds for problematic gambling or gambling disorder, but also includes individuals who, at a minimum, report sometimes or occasionally experiencing at least one behavioural symptom or adverse personal, social, or health- related consequence from gambling; this group represents the full range of risk severity. Language: policy makers, regulators, and academics increasingly refer to gambling harms to describe wide-ranging decrements to health and wellbeing associated with gambling. However, measurement instruments in gambling research often use terms, such as problem gambling, which can be stigmatising.18 In this Commission, guided by input from our lived experience contributors (appendix pp 3, 4), we adopt a person-centred approach, referring to people who gamble, people with gambling disorder, and people experiencing gambling harms.19 Where possible, we avoid the term problem gambling, except when we are describing data where its inclusion is necessary to be clear about the outcome measure used within the cited studies. e955 www.thelancet.com/public-health Vol 9 November 2024 The Lancet Public Health Commissions Advocacy groups representing people with first-hand experience of harms have effectively drawn attention to the health and wellbeing risks associated with gambling. In Georgia, for example, advocacy groups raised concerns about the impact of gambling on children, resulting in the legal age limit for gambling being raised to 25 years.29,30 In England, people bereaved by gambling- related suicide have raised the political and public profile of gambling harms, resulting in the inclusion of gambling as a potential risk factor for suicidality within the English Suicide Prevention Strategy 2023–2028.31 Such efforts have created some momentum for action. However, there remains an urgent need for stronger public health responses, with greater attention paid to the nature, prevalence, and distribution of gambling harms. Global outlook on the gambling industry and the importance of this moment Widespread digitisation and the global spread of gambling pose an escalating international challenge. The industry’s current growth trajectory is not only enabled by technological and financial advancements, but also by strong ties to regional and national governments. Advocates for industry expansion and legalisation stress that gambling operations can promote economic growth, generate tax revenues, and counter losses of domestic revenue to so-called black-market and offshore provision.32 Following these narratives, jurisdictions worldwide are increasingly legalising commercial gambling, choosing to regulate it rather than prohibit it. However, the manner of regulation needs to accommodate the reality that—to paraphrase Babor et al33—gambling is no ordinary commodity (panel 3) and its expansion comes with substantial risk. Consequently, there is an urgent need to design regula- tory controls and international frameworks sufficient to address public health risks associated with the ongoing expansion of the gambling industry. The need for effective regulatory controls and coordi- nated international frameworks is particularly acute in relation to the growth of online gambling in regions (notably LMICs) that are ill equipped to protect commu- nities from gambling harms and not prepared to deal with ancillary risks, such as the infiltration of criminal syndicates into gambling operations.34 Another high-priority area for attention—particularly considering risks for young people and the penetration into LMICs—arises from extensive gambling industry interdependencies and partnerships with sporting, leisure, and other affiliated services.35,36 Partnerships between professional sport and commercial gambling are now integral to the design of business practices and marketing strategies on both sides of the partnership, with each sector leveraging the other to drive growth. A newly pervasive social reality seems to be settling in: increased interest in sports now means increased exposure to gambling. Aims of the Commission To address the challenges posed by gambling, this Commission assembles a global team of experts in public health, gambling studies, global health policy, risk control, and regulatory policy; along with contributors with lived experience of gambling harms (appendix pp 3, 4). Contributions from people with lived experience enriched our perspectives on harms and reinforce the importance of such engagement for future studies. We set out a framework to understand the commercial and legal determinants of the modern commercial gambling industry. We explore how the industry is embedded Panel 3: Gambling—not an ordinary commodity Many gambling products have features that make them unlike most other commercially available commodities; these include the: Continuous and open-ended nature of product Unlike many other products (eg, food, alcohol, tobacco), for which there is a natural or physical limit to how much can be consumed in a set period, consumption of gambling can be repeated continuously, and with online provision can continue for 24 hours per day, with the only real limit on consumption being access to funds. Uncertainty of price Although a single bet has a single unit cost, an overall session of gambling does not have a fixed price because of the way that game structures and odds work. The true price of a gambling session is often unknowable to the consumer. In some forms of gambling, such as spread betting, the price can be higher than the original bet and unknown at the time the bet is placed. Odds and structures of gambling are opaque, and it is not always clear to consumers exactly what they are purchasing. This uncertainty sets gambling apart from other products. Product design Some gambling products are designed with particularly harmful features. The high speed, continuous, and seamless operation of many gambling products can generate immersive states that have been described as the experience of the zone—a state in which players are oblivious to the outside world, the passage of time, and the amount of money that they are spending. Asymmetry of insight Online gambling operators hold good data on consumers’ practices and preferences, and on the profitability of specific products. These data afford operators substantial potential to tailor products, adjust algorithms, and target their marketing. However, consumers do not have similar data on gambling products, often lacking basic information about key characteristics, such as price. See Online for appendix www.thelancet.com/public-health Vol 9 November 2024 e956 The Lancet Public Health Commissions within the wider political economy, and the implications for population health. Our examination encompasses the known harms asso- ciated with commercial gambling and the substantial threats to societal development and community health posed by the growth and expansion of the industry. We explore the commercial determinants of gambling and locate commercial products and practices within wider political–economic systems. We then review the existing knowledge on the prevalence of gambling disorder and on gambling harms, acknowledging the incomplete and partial evidence base. Finally, we review the gambling policy cycle, tracing how gambling legislation is framed, which preventive actions are adopted, and the strengths and weaknesses of different regulatory and enforcement regimens. In conclusion, we provide recommendations on policy, policy processes, and regulation. This Commission has two key objectives: first, to raise awareness of the public health risks associated with current trends in commercial gambling development; and second, to provide a set of recommendations for international, national, and regional actors to help prevent the global proliferation of gambling harms. The changes we document are fast moving. Our Commission is forward looking and thus focuses most closely on recent technological changes in commercial gambling and the specific challenges that they pose. We also offer readers—who might not be experts in the area—a primer that outlines how the existing gambling ecosystem works and highlights general trends and devel- opments that we consider to be of crucial importance. Based on the evidence presented in this Commission, our aim is to emphasise the importance of prioritising public health concerns over competing policy agendas when formulating gambling policies and regulations. The protection of public health should now take prece- dence when it conflicts with economic interests, commercial profitability, and governments’ interest in revenue generation. The Commission argues the need for a public health approach to prevent gambling harms. What this means, and how it compares with the dominant responsible gambling paradigm, will be discussed first. Gambling as a public health issue Key features of a public health approach to gambling Awareness of the risks of gambling to the health of the public has a long lineage. Gambling disorder was rec- ognised within the ICD in 1977, followed by the American Psychiatric Association DSM in 1980. By 1994, gambling scholars were calling for the public health community to be alert to the threat of expand ing gambling legalisation, highlighting the need for funding to prevent and treat gambling harms.37 In 1999, Korn and Shaffer went further and argued that a whole- systems approach was required to reduce gambling harms.38 This perspective has continued to attract support since its introduction,39–44 but this has largely failed to translate into policy action.45,46 In addition, medicalised perspectives—which focus on intra-individual factors, such as co-occurring mental disorders, cognitive issues, and poor impulse control as the source of gambling harms—have dominated gambling scholarship. As a result, research-informed policy initiatives have remained mostly focused on encouraging individuals to control their own behaviours by emphasising individual responsibility (termed the responsibility model).47,48 However, a growing body of epidemiological evidence has highlighted patterns of increased risk of gambling harms among population sub-groups, such as children, young people, minority ethnic groups, and individuals who are the most socially and economically disadvan- taged, as well as the association of particular products and product features with increased risks of harm.28,49 Such findings and patterns resemble those discovered in relation to other potentially harmful products (eg, alcohol, tobacco, drug use, unhealthy diets, etc). Epidemiological analyses and a system-level perspective draw attention to the important role of the social, com- mercial, political, and legal determinants of gambling harms.50,51 The relevance of a public health approach, and the parallels with challenges relating to other unhealthy products, also motivate calls by gambling researchers for gambling harms to be deeply embedded within the public health community’s broader harm prevention agenda.40–44 The expansion and digitalisation of the gambling industry, coupled with increased sophistication of gambling products, has added greater urgency to these calls. Gambling industry business practices, which are somewhat similar to those used in other unhealthy commodity industries (often referred to as the so-called corporate playbook), cause concern.52,53 Growing attention to the commercial determinants of health50 has also generated the impetus for gambling harms to be viewed from a public health perspective. Numerous scholars have outlined frameworks for examining determinants of gambling harms to health.39–44,54 These scholars emphasise the need to recognise commer- cial, political, and economic factors that generate gambling harms, as well as social, interpersonal, and demographic characteristics—including age, gender, ethnicity, and psy- chological and socioeconomic factors—which influence their distribution throughout populations. Although gambling harms might affect anyone, a heavy burden falls on individuals who are socially disadvantaged. The social gradients along which gambling harms might unequally fall can reproduce and reinforce inequalities.55–61 Scholars emphasising determinants of gambling harms have pressed for increased attention to actions by commercial entities that can affect the extent and distribution of harms by influencing societal norms and policies and regulations governing product design, promotion, accessibility, and e957 www.thelancet.com/public-health Vol 9 November 2024 The Lancet Public Health Commissions geographical distribution. These factors, alongside others, influence individual and community behaviours and the distribution of gambling and gambling harms. The inter-relationship of commercial, political, and social determinants of gambling and gambling harms, high- lighting the central actions of commercial actors, are visualised in figure 1. Adopting a public health approach to the prevention and control of gambling harms would require govern- ment policy to give precedence to the protection of public health and wellbeing over other competing economic, financial, and commercial interests. Policy making processes, to preserve their central focus on public health, would need to be guarded or protected against influence from commercial interests. Academic research, to preserve its independence and credibility, would similarly need to be insulated or protected from the distortionary effects of commercial influence. Increased emphasis would be given to population-focused harm prevention approaches, such as restricting advertising and marketing practices to reduce exposure, and deliberately counteract- ing industry attempts to normalise gambling behaviours. Although policies targeted on specific individuals clearly remain an important part of a comprehensive approach to harm prevention and reduction, such policies are by themselves insufficient to address the systemic and powerful commercial determinants of gambling harms. These features of a public health approach are not unique to gambling but reflect consolidated learning regarding what a public health approach means in general, in improving and protecting population health. As in other similar areas, one consequence of the application of this approach would probably be a reduction in corporate profits to some degree. The WHO Global Alcohol Action Plan 2022–2030, endorsed by the 75th World Health Assembly,62 includes many similar precepts and actions, including a strong focus on protecting policy processes and research from commercial influence. A summary of how the public health framework, applied to gambling harms, would differ from the prevailing responsible gambling paradigm is presented in table 1. Public health: precaution and evidence The application of public health frameworks to the understanding of gambling harms has started to gather pace in the past decade.10,40–45 Nevertheless, the quality of the available evidence base, for now, remains suboptimal, particularly in relation to high-quality epi- demiological studies and reliable determinations of efficacy for specific interventions.63 However, there is already ample evidence of clear relationships between readily accessible, high-intensity commercial gambling opportunities and a range of mental and physical health conditions.64–81 Also, the fact that gambling harms befall other people who do not gamble themselves, including domestic partners and children, has been well documented.11,22,82 Taking a public health approach requires embracing two key principles: the precautionary principle, and the use of the best available evidence. With regards to the precautionary principle, Pearce argued that “the concepts of precaution and prevention have…always been at the heart of public health practice”.83 As technological change outstrips scientific knowledge, the possibility of consequential damage to health and wellbeing must be considered and prevented. For WHO, “irreparable mistakes must be avoided, such as those related to tobacco or asbestos, when people waited for definitive evidence far too long before springing to action”.84 There are four key components of the precautionary principle: “taking preventive action in the face of uncer- tainty; shifting the burden of proof to the proponents of an activity; exploring a wide range of alternatives to possibly harmful actions; and increasing public partici- pation in decision making”.85 The issue of what constitutes evidence is debated, but there is clearly a hierarchy of evidence, ranging from meta-analyses of randomised controlled trials as the gold standard, to what is called tacit evidence, including expert opinion, the values and habits of policy makers, or the views of those with experience of an issue. Such informa- tion can be useful in evidence-informed decision making, as WHO proposes,86 and is particularly relevant to research involving unhealthy commodity industries, where openness to multiple sources of evidence is important. For Knai and colleagues,52 “there is a shared strategy across unhealthy commodity industries to shape both sci- entific evidence and narratives about a sub-optimal public health evidence base, to suit their interests…a broader conception of what constitutes ‘good’ or ‘good enough’ Figure 1: The determinants of gambling and gambling harms Product and systems design (eg, structural characteristics of product, choice architecture) Commercial practices and partnerships (eg, marketing, data surveillance, commercial partnerships) Shaping political and regulatory agendas (eg, lobbying, shaping evidence base, control of data) Shaping public perceptions (eg, framing narratives and norms, corporate social responsibility policies) Political, legal, and social determinants Commercial actors Individual and community characteristics www.thelancet.com/public-health Vol 9 November 2024 e958 The Lancet Public Health Commissions evidence in this field is required, one which embraces a wider range of research. This will require the integration of mixed methods from diverse sources and disciplines including quantitative and qualitative traditions.” As Weiss87 has argued, the need for more research can be exploited by the industry for tactical purposes, mainly to delay action. Public health actors need to enhance their own playbook to counter this tactic where unhealthy commodity industries are concerned.88 “The key feature of science is not measurement (this is just a tool) but understanding”, noted Pearce.89 This enhanced under- standing includes specific focus on the products and practices deployed by the commercial gambling industry and how these actions fit within wider political, economic, and legal determinants of gambling. The following sections consider these aspects in detail. The commercial determinants of gambling Kickbusch and colleagues defined the commercial deter- minants of health as the influence of corporate activities on individual and social wellbeing.50,90 Applied to gambling, the term functions as an umbrella for various commercial practices that the gambling industry shares with other unhealthy commodity industries, such as alcohol and highly processed foods.91 The commercial determinants of gambling are increas ingly well understood. These determinants include various corporate practices designed to influence consumer behaviour, such as marketing and product design. The commercial determinants of gambling also include strategies described as a corporate playbook, including political framing, lobbying, and industry influence over research.91–93 Corporations have a fiduciary responsibility to maximise profits for their sharehold- ers,36,94 but the consequences of profit maximising behaviours by commercial gambling operators can include substantial harm (externalities) that is borne by consumers and their families, communities, and society generally. The business model of commercial gambling relies disproportionately on a small proportion of users who consume a substantial proportion of the products and generate the majority of industry profits.95,96 The so-called addiction surplus97 is particularly apparent in connection with the most harmful gambling products and formats, including, but not limited to, electronic gambling machines (EGMs) and casino style games (especially the online versions).26,98 Pareto estimates of Canadian gambling company data showed that the top 20% of most active people who gamble account for 92% of sports bets or 90% of online casino activity.99 A US study showed that in sports betting, 5·7% of people who gamble accounted for 80% of spending, whereas for online casinos, 4·9% of those who gamble accounted for 80% of revenues.100 Similar concentration effects were recently evidenced in Connecticut, USA.101 These so-called vital few are generally also the most disadvantaged and the most likely to experience gambling harms.26 Multiple studies have shown that both gambling consumption and the tax revenues associated with Responsible gambling framework Public health framework Focus On individuals who gamble: so-called problem gamblers Focus on population: gambling harm Scope Regulation of individual behaviour Regulation of systems, products, and environment Disorder model Disease model Commercial determinants of health, social determinants of health, and legal, political, and environmental determinants of health Main emphasis Freedom of choice, consumer sovereignty, caveat emptor regulation Freedom from harmful commodities, consumer protection regulation Range of interventions Largely downstream, individual-level interventions and treatment; some education programmes Uses a range of interventions; focuses on upstream determinants of harms and also includes midstream and downstream efforts Where effort and resources are maximised Much effort on treatment and some education and social marketing Incorporates treatment effort, but also emphasises the importance of harm prevention, early intervention, and harm minimisation Characteristic interventions Education, social marketing, signage, referral to therapies, codes of conduct, self-exclusion options Limiting accessibility and availability, pricing (where applicable), focus on product characteristics, mandatory precommitment, limiting or prohibiting marketing and advertising Evidence base Modest or poor for responsible gambling tools; evidence base developed for efficacy of cognitive behavioural therapy for treatment and some other therapies (but note issues with high attrition) Well developed in analogous areas (eg, alcohol), though requires adaptation to apply to gambling harms; emerging evidence of effective population-level interventions Regulatory orientation Self-regulation with little oversight, industry self-reporting, and voluntary codes of practice Regulatory specificity and effective enforcement Ecological frame The so-called problem gambler Environment, commercial determinants of health, social determinants of health, operators, and multiple government agencies Priority focus Responsible users People with lived experience of harms, communities, and societal impacts Table 1: Comparison of gambling policy paradigms e959 www.thelancet.com/public-health Vol 9 November 2024 The Lancet Public Health Commissions gambling are regressive in nature.28,55–60,102–104 The capacity for gambling to exacerbate or entrench disadvantage creates substantial ethical challenges for govern- ments.105,106 Even though governments recognise the need to regulate gambling for public interest purposes (as discussed in the legislative analysis section in this Commission), they frequently develop some degree of dependence on gambling revenues, whether directly through taxation, or via use of gambling revenues for public or social purposes. In the following sections, we discuss practices used by gambling operators and the gambling industry to shape individual gambling behaviours, as well as regulatory action, and wider societal framings of gambling issues. We begin with the broad ecosystem surrounding the commercial gambling industry. We then examine gambling products and commercial practices, and finally turn to the broader political–economic and policy contexts that shape the ways the gambling ecosystem operates and how these contexts are in turn shaped by the gambling ecosystem. The commercial gambling industry and its ecosystem The growth and existence of the commercial gambling industry depends on its relationships with a wide network (or ecosystem) made up of other commercial actors and surrounding structures. These include financial services firms, communication systems, and information technol- ogy, media, and sports organisations and charities, as well as legal, regulatory, and administrative systems.35,36 The commercial gambling ecosystem thus extends far beyond the operators that make up the industry itself. Gambling operators buy software and hardware from game designers and manufacturers. Gambling software development is a rapidly growing industry, such that some software companies represent some of the largest corporations in the gambling sector globally.107 Gambling software includes various products ranging from gambling apps to supporting software, streaming tech- nologies (eg, live casinos) and their control programmes, betting software, payment software, random number generators, and programmes related to result deter mination (displaying results, determining bonuses, determining results, calculating winnings).108,109 In some jurisdictions, including the UK and Sweden, gambling software developers are required to obtain a Business to Business license. The ecosystem also includes producers of information and communications technologies, as well as marketing and data systems that are not directly linked to gambling products. International financial systems are crucial for the instantaneous transfer of funds—often across platforms and jurisdictions—between people who gamble and operators. Fintech companies provide online banking and use new technologies (eg, artificial intelli- gence [AI] algorithms) to produce personalised financial services. These companies might also use decentralised finance banking apps and blockchain technology to decentralise and anonymise transactions. The online gambling industry uses such technologies widely for payment intermediation.110,111 Financial services companies provide credit for individuals who gamble. At the same time, financial institutions might connect with gambling corporations by investing in them as share- holders.36,110,112 Banking data shows a strong connection between gambling consumption and the uptake of high-cost instant loans or pay-day loans—another segment of the financial services industry.113 The gambling ecosystem involves relationships with mass media, social media, and strong ties to the sports industry for product promotion and partnerships. Sports leagues, teams, and individual athletes are widely sponsored by the gambling industry.114,115 Gambling adver- tising is disseminated across social media platforms and promotes both traditional and emerging gambling products (eg, betting on e-sports).116 Influencers are online personalities that have “the power to affect the purchasing decisions of others because of his or her authority, knowledge, position, or relationship with his or her audience”.117 Influencer marketing is particularly prevalent in sports betting promotion, where the boundaries between promotional and entertainment content are often unclear.118,119 Such forms of influencer marketing, as well as broader social media advertising, are particularly visible to children and young people.116 Governments and their administrative agencies, including regulators, associate with gambling operators in various ways and thus function as a part of the ecosystem. Governments can have multiple roles: as regulators, as providers, and as beneficiaries of gambling. State-owned gambling companies often contribute over 50% of their gross gambling revenue back to the state or to other earmarked public causes.35 Privately owned licensed companies pay a share of their gross gambling revenue back to shareholders, while also contributing to state revenues through taxation and license fees. Weak regulatory controls are often observed where governments have developed vested interests in com- mercial gambling operations.105,120,121 Regulation is further undermined by the paucity of resources available to regu- latory bodies, and their resulting inability to adequately address technological developments in the industry (as discussed later in the section on regulation). The task of regulatory oversight is further complicated by the presence of third-party regulatory structures (eg, test houses that ensure compliance with product standards), which have become increasingly commonplace and function as intermediaries between the gambling industry and regulators.122 The focus of these third-party regulatory structures is often narrow. For example, test houses focus on product standards in relation to trans- parency and fairness, but are not deployed to focus on safety. www.thelancet.com/public-health Vol 9 November 2024 e960 The Lancet Public Health Commissions An example of the complex inter-relationships within the commercial gambling ecosystem is provided by in-play betting, which offers bets on a range of events while a sports match is underway. This intensive form of betting is facilitated by an online infrastructure whereby real-time information is fed from commercial sporting data companies, supported by sports leagues and teams, to bookmakers and then from bookmakers to consumers via smartphone-based or web-based applica- tions. Contemporary sports betting is thus transformed into a high-speed, continuous form of betting, which is likely to be associated with increased risk of harms (panel 4).128 The range of financial and commercial part- nerships that are involved in delivering this in-play product creates a network of commercial co-dependen- cies tied to maintaining and promoting the interests of the commercial gambling sector. The interdependencies that make up the gambling eco system expand the power and reach of the gambling industry itself, making its products widely accessible and its practices deeply embedded. We will now turn to these products and practices. Commercial gambling products Product type and characteristics Commercial gambling is provided in a range of different products, some of which incorporate features that generate more harm than others (panel 4). These products can be provided in land-based as well as online formats. Major forms of commercial gambling include: casino-style forms, including table and card games, such as baccarat, blackjack, sic bo, fan tan, roulette or boule, craps, and poker; table games are also offered in fast, automated electronic formats that enable continuous use, as with electronic gambling machines (EGMs); EGM forms, such as video poker, video lotteries, slots, and poker machines; sports betting on a range of activi- ties, such as football, cricket, rugby, and horse and dog racing, but also on some newer forms of activity, such as electronic sports (e-sports), and any other competitive game; lotteries, such as national or sub-national lotteries, regularised subscription or automated entry lotteries, keno, scratch tickets, prize draws; and bingo, tradition- ally a number game operated for charity, but increasingly commercialised and digitised. Facilitated by its commercial ecosystem, the gambling industry is increasingly shifting towards digital-first products. Substantial segments of the industry are migrating land-based products to online formats and mobile platforms, as well as developing entirely new digital offerings (eg, in-play betting, hourly lottery draws). Online and app-based casino, EGMs, and sports betting products are the fastest growing industry sectors globally, with revenues forecast to grow from US$75·4 billion in 2021 to $205·6 billion in 2030.6 Given the association between online gambling formats and gambling harms, these trends should be seen as important. Product development and design To maximise profits, gambling corporations aim for their products to be used by the largest possible number of users for the greatest timeperiod.129,130 Gambling companies also compete for market share, particularly in online environments. Intense competition over the small but profitable proportion of consumers who gamble at high levels pushes companies to compete on the attrac- tiveness of the products that they provide.130,131 Gambling companies engage in a continual process of product development to attract customers and hold their attention for long periods.130 The drive for profit results in the production of faster, more intense, opaque, and (for the operators) profitable forms of gambling.132 As outlined in panel 4, many gambling products include design mechanics that encourage repeated and continued engagement. Termed “addiction by design”,130 many of these features are most evident within continuous forms of gambling products, such as EGMs and casino-type formats (both online and land-based versions). The aim of this design is to maximise the time spent on each product or device. Some have argued that EGM products are designed to encourage so-called play to extinction, the point at which users have exhausted all available funds.130 Introduction of these features has made traditionally less harmful products more intensive. The frequency of lottery draws has increased. Similarly, bingo has been transformed into a highly intensive online product, as have hybrid products, such as slingo (a combination of bingo and slots).133 Corporate bookmakers offer increasing personalisation of sports bets and betting combinations, as well as shifting their offers more towards in-play betting.131 Panel 4: Features associated with high-risk gambling products95,123–127 • High speed and high event frequency • High intensity and uninterrupted rhythm, including continuous or in-running play, high payout intervals, and multiple stake opportunities • Sensory characteristics, such as visual and auditory stimuli • Reward characteristics or reinforcement, such as intervals of paybacks, jackpots, bonuses, return to player ratio, in-game features, or odds of winning • Payment or monetary characteristics, including bet sizes or forms of payment, automated subscriptions, depositing and withdrawal systems, and access to money • Near misses and losses disguised as wins (eg, winning back less than the original stake) • Information characteristics, such as player involvement, messages suggesting control of chance, or ease of gambling • Availability-related characteristics, including both temporal and geographical availability and accessibility e961 www.thelancet.com/public-health Vol 9 November 2024 The Lancet Public Health Commissions Digitisation has accelerated the development of products and extended their reach. In particular, the migration of gambling products onto mobile devices, such as smart- phones, has made them more broadly accessible than ever before and at any time of day. In digital environments, platform design has an important role in making gambling products accessible and attractive. Persuasive design techniques and interfaces are used to shape consumer behaviour and to maximise user engagement. Data-driven algorithms are used to target the promotion of more attractive content to specific users.134,135 Software design features can include ease of use and attractiveness, and might include functionality enabling those who gamble to communicate with operators (eg, live chats).134,135 In contrast to other areas of product safety regulation, there are no universal technical standards or consumer protection regulations to govern the safety of gambling products, despite increased understanding of product characteristics associated with higher risks of harm. Boundary spanning products and consolidation The industry’s need to attract new customers, coupled with innovations in technology, has driven the produc- tion of hybrid forms of gambling products. Gambling-like products are emerging from outside the traditional gambling industry.9 Emerging hybrid formats include products that converge with other sectors, such as financial investment and gaming. Gambling is often embedded, directly or indirectly, into the architecture of many video games. Loot boxes are an in-game ran- domised reward mechanism within video games that involve a purchase and a chance-based outcome. Rewards can include in-game currency, power ups, or customisa- tion features.136 Loot box purchasing is common among gamers and is associated with problematic gambling.136 Alongside loot boxes, skin betting is another emerging gambling-like product. Skin betting consists of digital items won or bought within video games (ie, skins) being used as collateral for wagers on websites outside the original video game architecture. These practices are popular among young people.137,138 A longitudinal study of young adults found that skin betting was strongly associ- ated with long-term continuance of problematic gambling behaviours.137 The rapid growth of online video gaming tournaments has also enabled the propagation of e-sports betting, through which consumers are able to bet on the perfor- mance of professional player. E-sports bets are commonly broadcast live and are accompanied by intense virtual advertisements in chatrooms or social media platforms that are designed to appeal to young people. Engagement in e-sports betting is associated with high rates of tradi- tional gambling and high rates of problematic gambling.139,140 E-sports betting is available for various forms of payment, ranging from real-world currency to site-specific currencies, including skins, and cryptocur- rency.9 In addition to their use as a source of betting currency, crypto markets can also function as betting-like interfaces.141 Cross-selling (ie, marketing additional products to existing customers) is a common practice deployed by gambling corporations. However, cross-selling now also straddles the divide between gambling-like products (eg, gaming products with some gambling-like features) and gambling products. The evolution of sports betting within the USA provides an example. Before the extensive legali- sation of sports betting, the USA had an important market for daily fantasy sports betting (an extension of fantasy sports competitions), led by companies such as FanDuel and DraftKings, with as many as 9% of Americans taking part in daily fantasy sports.9,142 As sports betting became legalised in many states in the USA (from 2018 onwards), FanDuel and DraftKings converted their business models towards for-money sports betting, with both becoming leaders in the US-sports betting market. Their success attracted the attention of more traditional gambling con- glomerates, some of whom have added these firms and products to their rostrum.143 The key commodity held by FanDuel and DraftKings was their database of sport- interested Americans who could be converted to sports betting for-money as soon as it was legalised.9 Social casino games follow a similar model. Social casino games are played online for digital rather than fiat currency. These products generate profit via in-game purchases and advertising revenue, but also reinforce brand-recognition and loyalty, providing the potential to convert customers into real-money casino gamblers if the operator, or their commercial partners, were to push the business in that direction.9 In Australia, where online sports betting is legal, but online casino games are not, gambling operators have developed social casino games based on their most popular slot machine brand titles, arguably acting as a form of surrogate marketing, whereby the brand, but not the product, is promoted.144 These forms of emerging and gambling-like products are increasingly well established, but poorly regulated globally,145,146 with little enforcement and inadequate provision of standard consumer protections, such as age verification. Commercial gambling practices Marketing: advertising and sponsorship Like other industries, marketing, advertising, and spon- sorship are key for the growth of commercial gambling. Marketing expenses are among the main cost elements in gambling companies’ income statement reporting.35 Advertising is particularly important in jurisdictions with licensed and competitive markets, where compa nies vie for customer recruitment and retention. In the USA, spending on online gambling advertising was USD$1 billion in 2021, and was projected to grow in line with the rapid expansion of the industry.147 Several reviews have assessed the impact of product and brand advertising and gambling marketing on behaviours.23,148,149 Collectively, these reviews suggest that www.thelancet.com/public-health Vol 9 November 2024 e962 The Lancet Public Health Commissions exposure to gambling advertising and marketing is posi- tively correlated with gambling behaviour and gambling intentions; there is evidence of a dose–response relation- ship and that exposure to marketing promotes high-risk gambling behaviours.148 Population-level studies confirm that exposure to advertising and marketing is associated with increased rates of problematic gambling25,150–152 and that advertising and marketing can prompt unplanned spending, particularly among those who are experienc- ing gambling harms. Analysis of marketing content shows that the following features are commonly used: displaying gambling in a positive light, promoting narratives of gambling as leisure, and normalising gambling; appealing to children or young people, including through the use of cartoons or celebrities; promoting odds or complex bets with higher potential payoffs; and advertising financial incen- tives, such as bonuses or free bets.153 Many jurisdictions regulate gambling marketing content, especially messag ing deemed to be harmful (eg, content with direct appeal to children). Commercial gambling companies have developed global commercial partnerships with the sporting sector. These commercial relationships are analogous to those formed between sports organisations and the tobacco and alcohol industries, where sponsorship of sports by those industries has long been acknowledged to obscure the harmful impacts of their products, to enable targeting of the youth market, and to circumvent advertising bans on broadcast media.154,155 A review published in 2021 identified sport as a major target for gambling operators, with various social media strategies seeking to influence gambling behaviour.156 Gambling companies are now primary sponsors for major sports teams and leagues, using the profiles of teams and players for promotional purposes.155 In the English Premier League, 40% of shirt sponsors during the 2022–23 season were gambling companies.157 Public attention has focused on mainstream sports, but sponsor- ship extends to all sports, including professional e-sports leagues and championships that have distinct appeal to young audiences.158 In Australia, research has documented the effect of such arrangements, highlighting normative changes to young men’s perspective on gambling.152 In many jurisdictions, increased broadcast advertising and sports sponsorship by gambling companies has met resistance and calls for increased restrictions. Public pushback was evident in Canada where polling data showed that 48% of Canadians supported reductions in gambling advertising after advertising became wide- spread following the federal legalisation of single-game sports betting in 2021.159 Public concerns about the impacts of advertising and marketing have also seen several European jurisdictions take action to ban or restrict advertising and sponsorship, including Belgium, the Netherlands, Germany, Spain, Italy, Georgia, and Romania.160 In Spain, gambling sponsorship for football teams in the Spanish LaLiga or Secunda Division was banned, starting from the 2021–22 season.157 Social media and influencer culture The gambling marketing is now intertwined with social media, influencer, and streaming culture. Legal defini- tions and frameworks have typically lagged behind developments in social media marketing, complicating the task of regulating advertising and marketing.119 Gambling companies and marketing affiliates use social media accounts to advertise specific products and offers, and to promote brand identity and awareness. This practice can complicate accountability to existing regula- tions on advertising and marketing. Analysis of 417 Twitter accounts belonging to commercial gambling companies and their partners found that these accounts posted 536 339 tweets advertising specific bets or gambling opportunities over a 9-month period in 2018.116 A further 350 000 content marketing tweets, which aim to stimulate interest in products and brands without marketing them directly, were sent from these same accounts. This study found that the five biggest operators in the UK each post, on average, 78 tweets per day, with substantial increases around key sporting events.116 Young people often interact with this type of content. A UK study showed that 161 (73%) of 222 individuals aged 18–24 years and 140 (63%) of 221 individuals older than 25 years reported having seen gambling advertise- ments on social media at least once a week.161 Another UK study found that 317 (28%) of 1132 children aged younger than 16 years engaged with e-sports gambling advertising on Twitter.116 Social media advertising can be paid for directly or can be organic (and not paid for). Paid advertising uses data analytics on consumer preferences to target and person- alise marketing communications. Targeted groups might be those who follow gambling-related content or specific demographic groups, such as young males, who can then be continuously exposed to gambling advertising content.162 Organic advertising consists of posts on social media accounts (often corporate accounts), designed to be appealing enough for users to share within their own contact networks, and with the hope that such posts might go viral.119 These forms of social media advertising increase product visibility while blurring the lines between advertising and other content. Gambling companies use influencer culture to promote their brands and products. For example, an emerging Brazilian online casino brand partnered with a famous footballer, who live streamed a betting session via his account with a leading streaming service,163 despite the fact that this streaming service had theoreti- cally banned casino and slot streaming. Such is the importance of influencer and live streaming in promoting gambling products that gambling industry executives have developed platforms which continue to allow such services.164 Other macro influencers include e963 www.thelancet.com/public-health Vol 9 November 2024 The Lancet Public Health Commissions sports betting tipsters or affiliates who are paid by gambling operators or bookmakers to drive new customers to their platforms. Popular tipster channels can have over 100 000 followers.165,166 Gambling companies also pay nano-influencers and micro-influencers (ie, small-scale influencers) as slot and casino streamers on social media platforms. Concerns have been raised about gambling streaming cultures, especially the risk that children might be exposed to age-inappropriate content.167 In Indonesia, several small-scale influencers have been arrested for their links to illegal advertising of online gambling sites through social media or messaging services. All gambling activities are illegal in Indonesia, and the activities of these influencers have been linked to inter- national organised crime.168 Regulators are attempting to deal with the phenome- non of influencer marketing. In 2023, France banned influencer marketing of harmful products, including gambling.169 In Finland, the gambling regulator, National Police Board (Poliisihallitus), ran a publicity campaign on TikTok, Instagram, and YouTube to raise awareness of illegal influencer marketing of gambling.170 In Denmark, the gambling regulator, Danish Gambling Authority (Spillemyndigheden), partnered with Facebook to block posts and groups illegally promoting gambling.171 Profiling, targeting, and direct marketing Digitisation has enhanced the ability of gambling operators to capture detailed data about the performance of their products and the behaviour of their customers. Online gambling companies precisely target consumers using predictive algorithms, personalisation, and persua- sive technologies, and train sophisticated algorithms to enhance an individual’s user experience.156,172 Targeted forms of marketing include capitalising on sports fandom and promoting bonuses and other financial incentives with messaging, varied across users and user groups according to their revealed preferences.23,173 Data on consumers are shared widely across the gambling ecosystem and are used to profile customer behaviours. Some data sharing practices help to satisfy licensing obligations, such as fraud prevention and detection. Other practices serve purely commercial interests. An investigation in 2022 revealed that one British online gambling operator had shared personal consumer data with 44 third-party organisations (including companies specialising in fraud prevention analytics, in marketing, personalisation and profiling as well as social media companies).174 Gambling companies and affiliate marketers can use third-party data houses to identify new potential customers and target them.175 Researchers have also found data sharing practices between and within commercial parent groups, where registration with one brand results in automatic sign-up for another brand or product, or triggers direct marketing from other companies within the same parent group.176 Gambling regulators, concerned about the effects of digital surveillance infrastructures,177 have sought to restrict the ways in which gambling operators deploy data to target individuals or groups. In 2022, Belgium announced prohibitions on gambling marketing that targets young individuals, excluded players, and any individuals who have gambled in the past but not for some time.178 In the Netherlands, legislation prohibits the targeting of marketing offers using data on player prefer- ences.179 Several countries, including Norway, now require gambling companies to obtain customer consent before they use any personal data for marketing purposes.180 Online choice architecture Online gambling companies deploy online choice architecture to promote their products and encourage consumers to spend and keep spending.176,181,182 Online choice architecture includes design features for websites and apps that influence consumer choices and make it more difficult for consumers to stop or limit their engagement. Such features become especially harmful when they use so-called dark patterns and manipulative personalisation. Dark patterns are user interfaces that exploit cognitive biases and manipulate consumers into making choices against their best interests.183,184 These design features are particularly harmful when applied to high-risk online gambling. Reviews published over the past 5 years176,181,182,185 have found evidence of nagging behaviours—which include frequent pop-ups inviting play, invitations to deposit more at log out, repeating bets, and prompts to keep gambling after a round or session ends. Other manipulative practices include seeking to manipulate a consumer’s emotions in communications, and making the acceptance of offers or placing of bets look appealing. Sludging involves making it difficult for the consumer to take certain actions, like unsub scribing from marketing, closing an account, or making withdrawals from gambling accounts (while making deposits to those accounts remains easy and straightforward). The European Commission Directorate-General for Justice and Consumers argues that the outcome of such commercial practices is degradation of trust in digital markets and exploitation of consumer vulnerabilities.182 Gambling regulation needs to take account of the oppor- tunities afforded to gambling operators by digital infrastructures and advanced analytics, and to monitor closely the novel ways in which gambling corporations capitalise on these technologies to produce faster and more intense gambling products and more effective ways to market them. Keeping up, as a regulator in this field, is made harder by the rapid pace at which the industry designs and promotes new digital products and by the appearance of hybrid products that do not fit easily within traditional product categories and legal definitions. www.thelancet.com/public-health Vol 9 November 2024 e964 The Lancet Public Health Commissions The political economy of commercial gambling The commercial gambling ecosystem operates within a broad political and economic system that sets the limits for what it can and cannot do. Neoliberal policies designed to encourage economic growth, competition, and privatisation, and that are based on light-touch, self- regulatory systems90,91,186 have facilitated the growth of a small number of immensely powerful transnational corporations, not least within unhealthy commodity industries.53 This environment has also provided consid- erable impetus to the growth of the commercial gambling ecosystem and facilitated the digital transformation of industry products and practices. In this system, consumer protection is assumed to rely on consumer choice, rather than on strong regulation; and the emphasis on consumer responsibility and consumer sovereignty act to deflect attention away from the products and practices of the gambling industry and the nature of the wider commercial environment within which it operates.91,186 In this environment, the gambling industry has been able to reinforce and consolidate its power and influence. The corporate playbook The gambling industry and its ecosystem partners use their collective political and economic power to engage in strategies that protect their own business interests. The collection of such methods has been termed the corporate playbook.88,91,186 Research across a range of unhealthy commodity industries outlines deployment of the following tactics to protect business interests:88 attack and undermine legitimate science (eg, fund counter-studies, plant doubt, insist on the complexity of the issue, distort evidence and data, encourage research that aligns with industry narratives, etc); frame and reframe discussion and debate (eg, promote narratives of individual responsibility and consumer freedom over so-called nanny state regulation, and the idea that business is part of the solution to the problems generated by commercial activity); intimidate and vilify critics (eg, threats, smear tactics, lawsuits); camouflage actions (eg, create the appearance of independence, use front groups as spokespersons for the industry); influence the political process (eg, lobbying, political donations, block and weaken regulation, keep the revolving door turning); develop and propose corporate alternatives to government policies (eg, promote voluntary self-regulation and codes); deploy corporate social responsibility (eg, donations to good causes) to improve corporate image; and contest, avoid, or evade regulation and restrictive policies (eg, challenging policies in courts, exploiting legal loopholes, and com- mitting violations). Such strategies have been deployed by the gambling industry. These strategies have sought to frame public and policy perceptions of gambling, shape the evidence on which policy is based, emphasise the role of corporate social responsibility, exercise political influence, and promote self-regulation over prescriptive regulation. Framing Framing is a powerful aspect of commercial influence and is used to shape normative understanding of gambling. The industry frames its activities in ways that favour commercial and shareholder interests. The industry presents gambling as a source of employment and state revenue and a form of leisure and harmless fun for the majority who gamble responsibly.43,187–190 In this responsible gambling paradigm, harms are framed as the consequence of poor choices or individual deficits in self-control experienced by a minority of vulnerable indi- viduals, rather than arising from the nature of products and commercial practices.186 This kind of framing is used across several unhealthy commodity industries—such as alcohol and ultra-processed foods—as a means of aligning harm with consumption patterns rather than supply patterns. Such framing serves to divert “attention from the corporate practices, economic systems and political decisions that produce harm in the first place”.186,190 Stressing what are presented as the benefits of gambling, as well as the problems, influences how gov- ernments think about trade-offs involved in gambling regulation, and the options for control that they are likely to consider. A review of European gambling policy found four competing framings for gambling: public health perspective; consumer protection-related perspec- tive; economic benefits, and entertainment value of gambling.191 Industry narratives stressed the economic benefits and entertainment value.191 Tension arises when policies simultaneously aim to protect public health and promote revenue generation—especially given that industry revenues and profitability rely disproportionately on those individuals who are harmed. By arguing that restrictions on corporate practice would restrict the freedoms of the so-called responsible majority to protect the so-called vulnerable few, the gambling industry can label additional governmental controls as the (unwelcome) exercise of paternalism, articulated in the pejorative term nanny state. This kind of framing is a common tactic across unhealthy commodity industries.52 As a counter to such labelling, gambling regulations seldom, if ever, lay down restrictions on what individual consumers can and cannot do. Rather, they restrain cor- porations in terms of what products they are allowed to offer, and to whom, and what means and methods they might use in so doing. Restraining corporate behaviour should not be confused with removing individual freedoms. Bearing in mind the role of the state to protect citizens from harm, it is important to note that policy choices relating to the protection of populations almost never e965 www.thelancet.com/public-health Vol 9 November 2024 The Lancet Public Health Commissions lead to binary, all-or-nothing, responses. Societies choose degrees of intervention, or protection, which some interests might portray as paternalistic. Societies seek to balance freedoms of action (for some) with freedoms from harm (usually, for others). British philosopher Isiah Berlin distinguishes negative freedoms, the license to act in unrestrained ways, from positive freedoms, freedom from harm or potential harm. Applied to gambling, negative freedom relates to freedom for the industry to act in unrestrained ways, free from regulation, whereas positive freedom relates to the freedom of the population not to be harmed by gambling.192,193 Mature democracies all exercise degrees of so-called paternalism with respect to virtually every major public health risk. Consumer protection law operates to remove dangerous products from the marketplace, especially under conditions of information asymmetry wherein consumers could not be expected to know just how dangerous some products might be. The policy puzzle in controlling gambling harms involves finding an appro- priate or judicious balance: allowing some freedom of action for corporations and providing some level of pro- tection from harm for individuals and communities. Outright rejection of so-called paternalistic interventions would leave corporations totally unrestrained, and lead to substantial avoidable harm. Shaping the evidence base Shaping the evidence base is an important feature of the corporate playbook. Industry actors fund academic projects, formulate research questions and agendas that align with their perspectives and preferences, and attempt to discredit findings that are critical of their practices.194 The paucity of independent funding for gambling research has exacerbated this situation by creating a funding gap into which the industry has moved. As a result, the body of evidence that informs policy and regulation remains at best partial, and at worst biased or misleading. All these activities have helped develop an understand- ing of gambling that is built on two key propositions: that gambling is a productive and beneficial form of economic activity, and that gambling is a harmless recreational pursuit with only a small minority of so-called problem or disordered gamblers experiencing problems. Choices among research disciplines and research methods can reinforce these assumptions. For example, research informed by clinical and psychological perspec- tives focuses on individual characteristics of people experiencing problems with gambling, exploring cognitive, emotional, and personal characteristics that appear to increase the likelihood or severity of harms suffered.48 Research that measures the prevalence of gambling disorder, or so-called problematic gambling, throughout populations or population segments can be used by industry to keep the focus on individual and consumer behaviour.195 Population estimates of gambling disorder or problematic gambling from prevalence studies, based on diagnostic screens, find rates of gambling disorder of around 1% of the population.196 Such estimates are repeatedly used by the gambling industry to conceptual- ise harms as affecting a tiny minority of people. But this so-called tiny minority of people is not a tiny minority of the people who gamble. Many people do not gamble at all, or gamble only occasionally; so entire population estimates conceal the extent of harms among those who do actually engage in gambling, which is much greater. For these reasons, the Australian Productivity Commission concluded that using population estimates for policy purposes was essentially misleading.197 In addition, population-level studies only measure the small subset of harms directly and immediately experi- enced by those who gamble, generally omitting measurement of harms to others and long-term effects experienced over the course of a lifetime. A focus on population prevalence estimates of gambling disorder, as currently conceived, poorly articulates the full scale of the harms of gambling and the risks associated with specific gambling products.195 As discussed in the next section, comprehensive means of monitoring the impacts of gambling throughout populations, using approaches that capture the full extent of its harms and the differential impacts of product types, are required. Current approaches, with all the shortcomings described above, have failed to provide an adequate counterpoint to the responsible gambling framing. As a result, industry framings retain their power and continue to deflect attention away from commercial practices and harmful products. The gambling industry also exercises control over the types of data made available for research purposes. Gambling operators hold vast amounts of consumer data, but are not generally required to pass them along to researchers seeking to monitor patterns and trends.160 The gambling industry, therefore, might choose to make data available to selected researchers and for selected research projects—an arrangement that might preclude research that challenges industry narratives or criticises their practices.194,198 Asymmetries of information make it difficult for researchers and policy makers to gain a clear understand- ing of costs and benefits in relation to the gambling industry. Economic benefits are apparent and readily quantifiable. Data on tax revenues, employment figures, and financial contributions to earmarked causes are both available and persuasive.199,200 Commercial entities often stress that strengthening regulation of the industry would have negative effects on the economy by reducing gambling revenues (despite evidence suggesting that the impact might be somewhat mitigated by substituted expenditure in other entertainment sectors201). In com- parison with the economic benefits, the social costs of gambling are much harder to estimate and quantify. www.thelancet.com/public-health Vol 9 November 2024 e966 The Lancet Public Health Commissions Attempts to quantify costs have largely focused on the social cost of disordered gambling which, for all the reasons previously cited, necessarily and substantially underestimates the full impact. In the UK, the costs associated with problematic gambling were conservatively estimated at £1·4 billion, not accounting for the effects felt by individuals who do not gamble, on communities, or on society more broadly.202 In 2010, the Australian Productivity Commission estimated the social costs of so-called problematic gambling in Australia to be at least AUD$4·7 billion, to be weighed against benefits (eg, tax revenue and enjoyment of so-called recreational gamblers) of at least $12·1 billion.197 Estimates of the societal costs of so-called problematic gambling from other countries range between 0·3% and 1·0% of gross domestic product.203 In the Australian state of Victoria, a 2017 study estimated the social costs of gambling to be $7 billion,204 substantially higher than previous estimates of the social costs of problematic gambling alone and higher than estimates of state revenues from gambling taxes.79,197 Attempts to capture a more complete picture of social costs will naturally result in substantially higher estimates than those produced with a narrow focus on problematic gambling. More realistic estimates should, in turn, change the picture and shift perceptions about the significance of the costs. Political influence Framing gambling as an enjoyable leisure activity with minimal risks provides the gambling industry license to engage vigorously in lobbying and other political activity. Research has documented gambling industry influence across the policy cycle, affecting policy formulation, adoption, and implementation.191 Gambling industry actors have enormous financial resources at their disposal.205 Wide ranging lobbying efforts in the USA were used successfully in campaigns to legalise sports wagering