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van den Dool et al.1 raise questions about our recent study2 which initially relate to the variability in deprivation among practices, and management of missing data on gambling problems. As indicated in the paper, the study involved sampling of practices according to official metrics of population deprivation. This produced four practices from deprived areas (top 30% for deprivation in England), two practices from areas of low deprivation (bottom 30%), and three practices in the middle 40%, which we regard as indicating meaningful diversity. In contrast, we agree that usage of ‘zero fill’ techniques for missing data could underestimate the extent of gambling problems. We expect that underestimation will be modest (given that most missing data was attributable to patients reporting low intensity gambling), and suggest that conservative estimates are preferable to figures that may overstate such levels.
The final question from van den Dool et al.1 relates to ways of implementing recommendations for training and support for clinical staff. Working with practices in this study revealed ambivalence about whether gambling problems were a health-related concern (versus a social issue), and whether these could be prioritized given other pressures on primary care. In the UK, the Department for Culture, Media and Sport also leads the societal response to gambling, rather than the Department for Health. Gambling problems are not a priority for health policies and there is virtually zero public investment in research or services. These are funded instead by the gambling industry, notwithstanding concerns that commercial funding has pervasive negative implications for public health.3
In this challenging context, we make modest proposals for accruing evidence of service need; practices could pilot the administration of brief gambling screens (e.g., the Lie/Bet screen)4 alongside measures of other risk behaviours, and within patient intake questionnaires or health checks, while building links with specialist services that can support training and provide referral pathways. This information on the frequency of gambling problems, alongside studies of physical and mental health consequences,5 can be used to help increase acceptance of gambling as a health-related issue that is suitably addressed in general practice.
References
1. van den Dool M, Stoevelaar F, Mailuhu AKE, Oppewal A. Gambling problems in primary care: A cross-sectional study of general practices (eLetter). Br J Gen Pract 2017; Epub ahead of print.
2. Cowlishaw S, Gale L, Gregory A, McCambridge J, Kessler D. Identification of gambling problems in primary care: A cross-sectional study of general practices. Br J Gen Pract 2017;67(657):e274-79.
3. Adams P. Moral Jeopardy: Risks of accepting money from tobacco, alcohol and gambling industries. Cambridge: Cambridge University Press. 2016.
4. Johnson EE, Hamer R, Nora RM, Tan B, Eisenstein N, Engelhart C. The Lie/Bet Questionnaire for screening pathological gamblers. Psychol Rep 1997;80(1):83-8.
5. Cowlishaw S, Kessler D. Problem gambling in the UK: Implications for health, psychosocial adjustment and health care utilization. Eur Addict Res 2016;22: 90-98.