Prevalence and self-rated health and depression of family members affected by addictive disorders: results of a nation-wide cross-sectional study.

AIMS: To estimate the prevalence of family members affected by addictive disorders (FMA) with regard to various types of addictive disorders, and self-rated health and depression in the general population. DESIGN: Cross-sectional general population survey. SETTING: The German Health Update study (GEDA) 2014/2015, a nationally representative panel of German residents aged 15 years or older. PARTICIPANTS: A total of 24 824 residents aged 15 years or older. MEASUREMENTS: Participants were asked if they had a family member with current or past addictive disorder, the type of addiction and the relationship status. In addition, self-rated health and depression were assessed using standardized questionnaires. FINDINGS: Of the respondents, 9.5% [95% confidence interval (CI) = 9.0-10.0] reported being affected by a current addictive disorder of a relative (cFMA), with a further 4.5% (95% CI = 4.2-4.9) reported having been affected by the addictive disorders of a relative in the past but not within the last 12 months (pFMA). Most FMAs reported having been affected by disorders due to alcohol, followed by cannabis and other drugs. Compared with life-time non-FMAs, FMAs reported significantly (P < 0.001) higher odds ratios for depression (cFM = 2.437; 95% CI = 2.082-2.853; pFMA = 1.850; 95% CI = 1.519-2.253) and ill-health (cFMA = 1.574; 95% CI = 1.374-1.805; pFMA = 1.297; 95% CI = 1.082-1.555). CONCLUSIONS: In Germany, family members affected by addictive disorder are a substantial group within the general population. This group is characterized by ill-health and has not yet been adequately addressed by the addiction treatment system.

A public health approach to gambling regulation: countering powerful influences.

Often portrayed as a harmless leisure activity in the UK, gambling is being increasingly recognised as a public health concern. However, a gambling policy system that explicitly tackles public health concerns and confronts the dependencies and conflicts of interest that undermine the public good is absent in the UK. Although there is a window of opportunity to change the gambling policy system, with the UK Government's launch of a review of the Gambling Act 2005, the adoption of a comprehensive and meaningful public health approach is not guaranteed. Too often, government policy has employed discourses that align more closely with those of the gambling industry than with those of the individuals, families, and communities affected by the harms of gambling. In view of the well described commercial determinants of health and corporate behaviour, an immense effort will be needed to shift the gambling discourse to protect public health. In this Viewpoint, we seek to advance this agenda by identifying elements that need challenging and stimulating debate.

The case for developing a cohesive systems approach to research across unhealthy commodity industries.

OBJECTIVES: Most non-communicable diseases are preventable and largely driven by the consumption of harmful products, such as tobacco, alcohol, gambling and ultra-processed food and drink products, collectively termed unhealthy commodities. This paper explores the links between unhealthy commodity industries (UCIs), analyses the extent of alignment across their corporate political strategies, and proposes a cohesive systems approach to research across UCIs. METHODS: We held an expert consultation on analysing the involvement of UCIs in public health policy, conducted an analysis of business links across UCIs, and employed taxonomies of corporate political activity to collate, compare and illustrate strategies employed by the alcohol, ultra-processed food and drink products, tobacco and gambling industries. RESULTS: There are clear commonalities across UCIs' strategies in shaping evidence, employing narratives and framing techniques, constituency building and policy substitution. There is also consistent evidence of business links between UCIs, as well as complex relationships with government agencies, often allowing UCIs to engage in policy-making forums. This knowledge indicates that the role of all UCIs in public health policy would benefit from a common approach to analysis. This enables the development of a theoretical framework for understanding how UCIs influence the policy process. It highlights the need for a deeper and broader understanding of conflicts of interests and how to avoid them; and a broader conception of what constitutes strong evidence generated by a wider range of research types. CONCLUSION: UCIs employ shared strategies to shape public health policy, protecting business interests, and thereby contributing to the perpetuation of non-communicable diseases. A cohesive systems approach to research across UCIs is required to deepen shared understanding of this complex and interconnected area and also to inform a more effective and coherent response.

Setting Limits: Gambling, Science and Public Policy-summary of results.

The gambling industry has grown into a global business in the 21st century. This has created the need for a new emphasis on problem prevention. This article highlights the core themes of the book Setting Limits: Gambling, Science and Public Policy, taking a broad view of the consequences of gambling for society as a burden on health, well-being and equality. The book covers the extent of gambling and gambling-related problems in different societies and presents a critical review of research on industry practices, policy objectives and preventive approaches, including services to people suffering from gambling and its consequences. It discusses the developments in game characteristics and gambling environments and provides evidence on how regulation can affect those. Effective measures to minimize gambling harm exist and many are well supported by scientific evidence. They include restrictions on general availability as well as selective measures to prevent gamblers from overspending. The revenue generated from gambling for the industry, governments, and providers of public services funded from gambling returns presents an obstacle to developing policies to implement harm-reduction measures. A public interest approach must weigh these interests against the suffering and losses of the victims of gambling.

Measuring Coping Among Family Members with Substance-Misusing Relatives: Testing Competing Factor Structures of the Coping Questionnaire (CQ) in England and Italy.

Background: The Coping Questionnaire measures affected family members' responses to their relatives' substance misuse related problems. The Coping Questionnaire examines three main coping strategies: engaged, tolerant-inactive, and withdrawal coping. Objectives: The aim of the current study was to compare competing conceptual measurement models across two countries, including one-factor, three-factor, and higher order factor models. Methods: Secondary analysis of data from five previous studies was conducted. Samples of affected family members from England (N = 323) and Italy (N = 165) were aggregated into two country specific groups. Series of confirmatory factor analyses were performed to test the degree of model fit and the effects of socio-demographic variables on the coping factors. Results: A bifactor model fitted the data most closely relative to the one- and three-factor models. High rates of common variance (60-65%) were attributable to the general coping factor, while a high proportion of the variance related to the withdrawal coping subscale score was independent (66-89%) of the general coping factor. Family members' country, age, gender, the type of relationship and the main problematic substance had significant effects on the coping factors. Conclusions: A bifactor model related to coping behaviors is consistent with the theoretical assumptions of the general coping literature. The concept of a general coping factor also fits the theoretical assumptions of the stress-strain-coping-support model, with family members showing a general tendency to cope with the harmful circumstances which arise due to substance misuse.

Systems Thinking as a Framework for Analyzing Commercial Determinants of Health.

Policy Points: Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community. One reason is the considerable influence of the "commercial determinants of health": NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking. This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions. CONTEXT: The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual-level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors. METHODS: Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy. FINDINGS: Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions. CONCLUSIONS: It should be possible to apply the principles of systems thinking to other complex public health issues, not just NCDs. Such an approach should be tested and refined for other complex public health challenges.

Coping strategies and support structures of addiction affected families: A qualitative study from Goa, India.

INTRODUCTION: Despite the large burden of a relative's drinking on their family members, the latter's perspectives and experiences are largely neglected. The aims of this article are to assess the coping strategies used by affected family members (AFMs) in Goa, India, and to examine the nature of the support they have for dealing with their drinking relative. METHOD: In-depth interviews were conducted with adult AFMs selected through purposive and maximum variation sampling. Data was analyzed using thematic analyses. RESULTS: The commonly used coping strategies included accommodating to the relative's behavior, financially adapting to their means, self-harm, attempting to reason with the drinking relative, covert intervening, and avoiding fights and arguments. There was a general reluctance to seek support, and the type and quality of support that was available was also limited. Support from neighbors or relatives was primarily through providing a "listening ear" or financial support. Religious and spiritual pursuits were commonly used to seek solace, and to manage negative thoughts and feelings. Formal support was sought for themselves or the relative through existing health services and Al-Anon, and occasionally from the police. DISCUSSION: AFMs experience a considerable amount of strain in relation to their relative's drinking, and have to rely on different ways of coping and social support, as is available to them. Although there is a universality to the experiences of families affected by addictions, this must be interpreted with caution, as it is also accompanied by variations in cultural factors related to these experiences. (PsycINFO Database Record

Psychosocial interventions for addiction-affected families in Low and Middle Income Countries: A systematic review.

AIM: To review the literature on psychosocial interventions for addiction affected family members in Low and Middle Income Countries (LMIC). METHODS: A systematic review with a detailed search strategy focussing on psychosocial interventions directed towards people affected by addiction without any gender, year or language specifications was conducted. Identified titles and abstracts were screened; where needed full papers retrieved, and then independently reviewed. Data was extracted based on the aims of the study, to describe the modalities, acceptability, feasibility and effectiveness of the interventions. RESULTS: Four papers met our selection criteria. They were published between 2003 and 2014; the total sample size was 137 participants, and two studies were from Mexico and one each from Vietnam and Malaysia. The predominantly female participants comprised of parents, spouses and siblings. The common components of all the interventions included providing information regarding addiction, teaching coping skills, and providing support. Though preliminary these small studies suggests a positive effect on affected family members (AFM). There was lowering of psychological and physical distress, along with a better understanding of addictive behaviour. The interventions led to better coping; with improvements in self-esteem and assertive behaviour. The interventions, mostly delivered in group settings, were largely acceptable. CONCLUSIONS: The limited evidence does suggest positive benefits to AFMs. The scope of research needs to be extended to other addictions, and family members other than spouse and female relatives. Indigenous and locally adapted interventions are needed to address this issue keeping in mind the limited resources of LMIC. This is a field indeed in its infancy and this under recognised and under-served group needs urgent attention of researchers and policy makers.

[Cost-effectiveness of a brief intervention to support indigenous women in Hidalgo (Mexico) who live with alcohol abusers]. / Costo-efectividad de una intervención breve de apoyo a mujeres indígenas de Hidalgo, México, que viven con consumidores excesivos de alcohol.

Objective Estimate the cost-effectiveness ratio of a five-step brief intervention aimed at reducing the stress and symptoms of depression caused by living with an alcohol abuser. Methods The cost-effectiveness analysis was carried out with a decision tree, based on symptoms of depression measured on the CES-D scale. The effectiveness of the brief intervention was evaluated by comparing a group of indigenous women who received the intervention (n = 43) with a similar group who did not (n = 30). The groups were evaluated before, immediately after, and 12 months after the intervention, in the state of Hidalgo (Mexico). Pharmacological treatment was selected for comparison, using different estimates. Cost-effectiveness and incremental cost-effectiveness ratios were used to calculate the value of the remission of depressive symptoms. Sensitivity analyses were also conducted. Results The brief intervention turned out to be more effective than the pharmacological one in terms of the remission of depressive symptoms. Its cost was also lower ($US 31.24 versus $US 107.60). The brief intervention would cease to be cost-effective only if its cost increased by 338% or more, or if its effectiveness were 22.8% or less. Conclusions The five-step brief intervention is a cost-effective option that results in significant reductions in depressive symptoms in indigenous women caused by living with alcohol abusers. It is also an affordable option for primary mental health care.

Could the Substance Misuse of a Relative be an Important Factor for Those Seeking Help for Anxiety and Depression? A Preliminary Prevalence Study within Improving Access to Psychological Therapies (IAPT).

BACKGROUND: The psychological difficulties and emotional impacts resulting from the substance use of close relatives constitute a large, underestimated and frequently unidentified health burden. The development of primary care mental health services in response to the Improving Access to Psychological Therapies initiative provides an opportunity to investigate this in more depth. AIMS: A preliminary exploration of prevalence of IAPT service-users being treated for moderate-severe depression and/or anxiety who report that they have relatives with alcohol and/or drug problems. To explore the characteristics of the sample including comparison with those without a substance misusing relative. METHOD: One hundred service users completed a brief questionnaire. Routine data on depression and anxiety symptoms were accessed for the full consenting sample. Descriptive statistics were used to explore the family members of substance users and differences to the rest of the sample. RESULTS: Twenty-two of the 100 IAPT service users reported having a close relative whose use of substances was of concern to them. The group with a relative who used substances were more depressed at the beginning of treatment than the rest of the sample. CONCLUSIONS: A significant number of people seeking psychological help for depression and anxiety within IAPT services reported being concerned about a close relative who misuses substances. They may be more distressed than those without a relative who misuses substances. Further exploration is warranted but preliminary findings indicate that this is an important research area with significant clinical implications.

Costo-efectividad de una intervención breve de apoyo a mujeres indígenas de Hidalgo, México, que viven con consumidores excesivos de alcohol / Cost-effectiveness of a brief intervention to support indigenous women in Hidalgo (Mexico) who live with alcohol abusers

Objetivo. Estimar la razón de costo-efectividad de una intervención breve de cinco pasos dirigida a reducir el estrés y los síntomas depresivos causados por convivir con un consumidor excesivo de alcohol. Métodos. El análisis costo-efectividad se realizó usando un árbol de decisión y se basó en los síntomas depresivos medidos con la escala CES-D. La efectividad de la intervención breve se evaluó comparando un grupo de mujeres indígenas que recibieron la intervención (n = 43) con otro similar sin intervención (n = 30). Los grupos se evaluaron antes, inmediatamente después de la intervención y a los 12 meses y se llevó a cabo en el Estado de Hidalgo, en México. El tratamiento farmacológico fue seleccionado como alternativa de comparación utilizando distintas estimaciones. Para evaluar el valor de la remisión de los síntomas de depresión se emplearon las razones de costo- efectividad y costo-efectividad incremental. Asimismo, se realizaron análisis de sensibilidad. Resultados. La intervención breve resultó ser más efectiva que la farmacológica en la remisión de síntomas depresivos y su costo fue más bajo ($US 31,24 y $US 107,60, respectivamente). Solo si la intervención breve incrementara su costo por encima de 338% o si su efectividad fuera menor de 22,8% dejaría de ser costo-efectiva. Conclusiones. La intervención breve de cinco pasos es una alternativa costo-efectiva con la cual se consiguen reducir significativamente los síntomas de depresión de las mujeres indígenas ocasionados por convivir con un consumidor excesivo de alcohol, así como una opción accesible para la atención de la salud mental en el primer nivel de atención.

Objective. Estimate the cost-effectiveness ratio of a five-step brief intervention aimed at reducing the stress and symptoms of depression caused by living with an alcohol abuser. Methods. The cost-effectiveness analysis was carried out with a decision tree, based on symptoms of depression measured on the CES-D scale. The effectiveness of the brief intervention was evaluated by comparing a group of indigenous women who received the intervention (n = 43) with a similar group who did not (n = 30). The groups were evaluated before, immediately after, and 12 months after the intervention, in the state of Hidalgo (Mexico). Pharmacological treatment was selected for comparison, using different estimates. Cost-effectiveness and incremental cost-effectiveness ratios were used to calculate the value of the remission of depressive symptoms. Sensitivity analyses were also conducted. Results. The brief intervention turned out to be more effective than the pharmacological one in terms of the remission of depressive symptoms. Its cost was also lower ($US 31.24 versus $US 107.60). The brief intervention would cease to be cost-effective only if its cost increased by 338% or more, or if its effectiveness were 22.8% or less. Conclusions. The five-step brief intervention is a cost-effective option that results in significant reductions in depressive symptoms in indigenous women caused by living with alcohol abusers. It is also an affordable option for primary mental health care.

Costo-efectividad de una intervención breve de apoyo a mujeres indígenas de Hidalgo, México, que viven con consumidores excesivos de alcohol / Cost-effectiveness of a brief intervention to support indigenous women in Hidalgo (Mexico) who live with alcohol abusers

RESUMEN Objetivo Estimar la razón de costo-efectividad de una intervención breve de cinco pasos dirigida a reducir el estrés y los síntomas depresivos causados por convivir con un consumidor excesivo de alcohol. Métodos El análisis costo-efectividad se realizó usando un árbol de decisión y se basó en los síntomas depresivos medidos con la escala CES-D. La efectividad de la intervención breve se evaluó comparando un grupo de mujeres indígenas que recibieron la intervención (n = 43) con otro similar sin intervención (n = 30). Los grupos se evaluaron antes, inmediatamente después de la intervención y a los 12 meses y se llevó a cabo en el Estado de Hidalgo, en México. El tratamiento farmacológico fue seleccionado como alternativa de comparación utilizando distintas estimaciones. Para evaluar el valor de la remisión de los síntomas de depresión se emplearon las razones de cos-to-efectividad y costo-efectividad incremental. Asimismo, se realizaron análisis de sensibilidad. Resultados La intervención breve resultó ser más efectiva que la farmacológica en la remisión de síntomas depresivos y su costo fue más bajo ($US 31,24 y $US 107,60, respectivamente). Solo si la intervención breve incrementara su costo por encima de 338% o si su efectividad fuera menor de 22,8% dejaría de ser costo-efectiva. Conclusiones La intervención breve de cinco pasos es una alternativa costo-efectiva con la cual se consiguen reducir significativamente los síntomas de depresión de las mujeres indígenas ocasionados por convivir con un consumidor excesivo de alcohol, así como una opción accesible para la atención de la salud mental en el primer nivel de atención.

ABSTRACT Objective Estimate the cost-effectiveness ratio of a five-step brief intervention aimed at reducing the stress and symptoms of depression caused by living with an alcohol abuser. Methods The cost-effectiveness analysis was carried out with a decision tree, based on symptoms of depression measured on the CES-D scale. The effectiveness of the brief intervention was evaluated by comparing a group of indigenous women who received the intervention (n = 43) with a similar group who did not (n = 30). The groups were evaluated before, immediately after, and 12 months after the intervention, in the state of Hidalgo (Mexico). Pharmacological treatment was selected for comparison, using different estimates. Cost-effectiveness and incremental cost-effectiveness ratios were used to calculate the value of the remission of depressive symptoms. Sensitivity analyses were also conducted. Results The brief intervention turned out to be more effective than the pharmacological one in terms of the remission of depressive symptoms. Its cost was also lower ($US 31.24 versus $US 107.60). The brief intervention would cease to be cost-effective only if its cost increased by 338% or more, or if its effectiveness were 22.8% or less. Conclusions The five-step brief intervention is a cost-effective option that results in significant reductions in depressive symptoms in indigenous women caused by living with alcohol abusers. It is also an affordable option for primary mental health care.

Ahead of its time: 40 years after the advice versus treatment family study.

Griffith Edwards' proposal for the alcohol 'treatment versus advice' study--also known as 'the family study'--illustrates how ahead of his time he was. The sample consisted of 100 married men who attended with their wives for a comprehensive assessment. Those randomized to 'advice' were told that the responsibility for attaining the goal of abstinence lay in the patient's hands, supported by his wife, that no further intervention was indicated, but that the research social worker would 'keep a watching brief' by visiting the home every 4 weeks for 12 months. Across multiple outcome measures there was no evidence that 'treatment'--considerable in amount by modern standards--was better than advice. Conversely, marital variables such as wives' alcohol-related hardship were significantly predictive of the outcome of the drinking problem. The study was arguably one of the principal sources of the whole 'brief treatments'/'brief interventions' movement which gathered momentum from then on and which, arguably, has itself become the conventional wisdom. The findings questioned the very nature of the addiction change process, suggesting that non-specific factors might be the more important, an issue that still remains unresolved. It is less clear that the study has left such a mark in terms of the development of a family and social model of addiction treatment and change. For example, it continues to be a struggle to help treatment organizations to become more family-inclusive.

Heavy drinking days and mental health: an exploration of the dynamic 10-year longitudinal relationship in a prospective cohort of untreated heavy drinkers.

BACKGROUND: Identifying dominant processes that underlie the development of other processes is important when evaluating the temporal sequence between disorders. Such information not only improves our understanding of etiology but also allows for effective intervention strategies to be tailored. The temporal relationship between alcohol intake and mental health remains poorly understood, particularly in nonclinical samples. The purpose of this study was to disentangle the dominant temporal sequence between mental health and frequency of heavy drinking days. METHODS: We report a 10-year (1997 to 2007) prospective cohort study of 500 respondents (74% male) from the Birmingham Untreated Heavy Drinkers project. Participants were aged 25 to 55 years at baseline, drinking a minimum of 50/35 U.K. units of alcohol for men/women on a weekly basis, and were not seeking treatment for their alcohol use upon recruitment into the study. Heavy drinking days were defined as consuming 10/7+ U.K. units of alcohol in a single day for men/women. Mental health was assessed using the mental health component score of the SF-36 questionnaire. Dynamic longitudinal structural equation models were used to test competing theoretical models (frequency of heavy drinking days leading to changes in mental health scores and vice versa) and a reciprocal relationship (both mental health scores and the frequency of heavy drinking days influencing changes in each other). RESULTS: A model whereby mental health scores were predictors of change in the frequency of heavy drinking days was of best fit. In this model, mental health scores were negatively related to change in heavy drinking days (ß -0.80, SE 0.28) indicating that those with higher mental health scores (i.e., better functioning) made larger reductions in the number of heavy drinking days over time. CONCLUSIONS: Mental health appears to be the stronger underlying process in the relationship between mental health and frequency of heavy drinking days.

Attitudes towards gambling in Finland: a cross-sectional population study.

BACKGROUND: Attitudes towards gambling influence gambling behaviour but also reflect the existing gambling policy in a society. However, studies examining general attitudes towards gambling at the population level are scarce. The first aim of this study was to investigate general attitudes of the Finnish population towards gambling. The second aim was to explore the association of socio-demographics, gambling behaviours, being a concerned significant other (CSO) of a problem gambler and perceived health and lifestyle with attitudes towards gambling among the Finnish population. METHODS: A cross-sectional study was performed by structured telephone interview on a random sample of 15-74-year-old Finns between October 2011 and January 2012. The data (n = 4484) was weighted based on age, gender and region of residence. Attitudes towards gambling were measured with the eight-item version of the Attitude Towards Gambling Scale (ATGS-8). A factor analysis was performed to test the structure of the Finnish version of the ATGS-8. The data were analysed using one-way ANOVA test, t-test and multiple regression analysis. RESULTS: On average, attitudes of Finns towards gambling were negative. The most significant factors associated with positive attitudes towards gambling were male gender, young age, 12 years or more education and net income more than 2000€, low score on gambling severity, being a non-CSO of a problem gambler and high alcohol consumption CONCLUSIONS: The association between young age, male gender, high net income and risky alcohol consumption, and favourable gambling attitudes was strong, and also reflects risky gambling behaviour. Experiencing gambling-related harms caused by one's own or significant other's excessive gambling seems to indicate unfavourable attitudes towards gambling.

Addiction in the family is a major but neglected contributor to the global burden of adult ill-health.

This paper offers a conceptual overview of a neglected field. Evidence is presented to suggest that, globally, addiction is sufficiently stressful to cause pain and suffering to a large but uncounted number of adult affected family members (AFMs), possibly in the region of 100 million worldwide. A non-pathological stress-strain-coping-support model of the experience of AFMs is presented. The model is based on research in a number of different sociocultural groups in Mexico, England, Australia and Italy and aims to be sensitive to the circumstances of AFMs in low and middle income countries and in minority ethnic and indigenous groups as well to those of majorities in wealthier nations. It highlights the social and economic stressors of many kinds which AFMs face, their lack of information and social support, dilemmas about how to cope, and resulting high risk for ill-health. The public sector and personal costs are likely to be high. Attention is drawn to the relative lack of forms of help designed for AFMs in their own right. A 5-Step form of help aiming to fill that gap is briefly described. Family members affected by addiction have for too long been a group without a collective voice; research and action using the model and method described can make a contribution to changing that state of affairs.

Gambling in Britain: the application of restraint erosion theory.

AIM: To provide an overview of gambling and problem gambling in Britain, including historical background, current regulations and the recognition, prevalence and treatment of problem gambling. METHODS: A new theory, Gambling Restraint Erosion Theory (GRET), is used as a framework for understanding the history of gambling regulation in Britain in the 20th century and evidence about the prevalence of gambling and problem gambling, as well as public attitudes towards gambling, in Britain in the first decade of the 21st century. FINDINGS: Restraints on gambling were progressively dismantled as regulation moved from partial prohibition, to tolerance, and then to liberalization by the turn of the millennium. British adult gambling prevalence surveys carried out in 1999/2000, 2006/07 and 2009/10 suggest that the British public is still relatively restrained in its engagement in gambling, and is still suspicious of gambling. There is evidence from the last of those surveys that engagement in some forms of gambling, and the prevalence of problem gambling, have risen, and that attitudes have become less negative towards gambling. CONCLUSIONS: Restraints which kept British gambling circumscribed, and the prevalence of problem gambling low, may be in the process of being eroded. Meanwhile, an effective public health response to problem gambling is constrained by lack of Department of Health interest and a failure to develop a research and treatment base independent of the gambling industry.