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Gambling Disorder

A Hidden Public Health Challenge

BY Bill Stein 

Gambling — in its various forms — has become deeply embedded in American culture. In 2025, commercial gaming in the United States generated a record $78.7 billion in gross gaming revenue, according to the American Gaming Association. At the same time, a 2026 Gallup survey found that 45% of U.S. adults reported participating in some form of gambling during the previous year. And gambling is no longer confined to casinos, racetracks or lottery counters. Sports betting, casino games, poker, lottery games, prediction markets, online gaming and other forms of wagering can be accessed from a smartphone or computer, often at any hour of the day. For physicians, the important question is not simply how many people gamble. It is how many patients are experiencing harm — and how many of them are never asked about it.

Gambling Disorder is a Medical Condition

Gambling disorder is a behavioral addiction recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, within the category of addictive disorders. The World Health Organization (WHO) also recognizes gambling disorder in the International Classification of Diseases, 11th revision.

WHO defines the disorder in terms of three core characteristics — impaired control over gambling, increasing priority given to gambling over other activities and continuation of gambling despite negative consequences. Importantly, gambling-related harm can occur even when a person does not meet the full criteria for a clinical diagnosis.

That distinction matters in a medical setting. A patient does not have to be gambling away a retirement account or facing bankruptcy before the behavior becomes clinically relevant. Gambling disorder is sometimes called the “hidden addiction.” Unlike alcohol or substance-use disorders, there may be no obvious physical signs. A person can maintain a job, appear financially secure and interact normally with family and friends while gambling privately for hours each day. With smartphones and online platforms, gambling can take place without anyone else knowing it is happening.

That secrecy is often reinforced by shame, embarrassment and denial. Patients may minimize how much they gamble or how much money they are losing. They may describe gambling as entertainment even when it has begun to interfere with sleep, relationships, work or financial stability.

Gambling disorder is sometimes called the “hidden addiction.”

Some warning signs that physicians might spot in their patients include:

• Frequently talking about gambling or thinking about the next opportunity to gamble
• Increasing the amount of money or time spent gambling
• Trying unsuccessfully to cut back or stop
• Chasing losses by returning to gamble in an attempt to win money back
• Borrowing money, selling possessions or using savings to fund gambling
• Hiding or lying about gambling activity or losses
• Experiencing irritability, anxiety or restlessness when attempting to stop
• Gambling despite problems with work, school, finances or relationships
• Using gambling as a way to escape stress, depression or other emotional problems

These signs may not appear in a traditional medical history unless someone asks.

Health vs. Financial Consequences

The financial consequences of gambling disorder can be devastating, but they are only part of the picture.

Gambling-related harm is associated with anxiety, depression, stress, sleep problems and other mental health concerns. WHO identifies financial distress, relationship breakdown, family violence, mental illness and suicide among the potential harms associated with gambling.

The consequences can ripple outward. A patient may begin missing work, school or family obligations. A spouse may discover hidden debt or depleted savings. Parents may be unable to pay household expenses. Patients may experience escalating credit-card debt, loan defaults, bankruptcy or even illegal activity to obtain money for gambling.

The affected population is considerably larger than the person who is gambling. WHO cites research suggesting that approximately six other people may be affected by the gambling of one person experiencing high-risk gambling. Those affected others can include spouses, children, parents, friends, coworkers and other family members. The economic cost is substantial as well. The National Council on Problem Gambling estimates the annual social cost of problem gambling in the United States at approximately $14 billion, including health care and criminal justice costs, job loss, bankruptcy and other consequences.

Biological Components

Gambling disorder should not be viewed simply as a failure of willpower. Research indicates that genetic and environmental factors both contribute to vulnerability. A large twin-study analysis found substantial genetic contributions to gambling disorder liability, with one analysis estimating genetic factors accounted for about 60% of variation in liability. A broader meta-analysis of twin studies found moderate genetic influence on gambling behavior and somewhat higher estimates for disordered gambling.

There is no single "gambling gene." Rather, researchers have identified overlap between genetic vulnerabilities associated with gambling disorder and other psychiatric and addictive conditions. Neurobiology is also relevant, with research showing involvement with the brain's reward and reinforcement circuitry, including the mesocorticolimbic dopamine system. Dopamine appears to be involved in reward anticipation, reinforcement and sensitivity to uncertainty. Serotonergic and noradrenergic systems also appear to contribute to impulse control, arousal and other aspects of gambling behavior.

Additionally, emerging research suggests that fluctuations in ovarian hormones may influence impulsivity and compulsive behaviors during certain life stages or transitions. These changes may represent another factor that increases vulnerability to developing gambling disorder in some individuals.

Physicians should also be mindful of medications that may increase impulsive or compulsive behaviors. Recognizing these potential effects when prescribing and monitoring patients can be an important part of identifying and addressing gambling-related concerns.

The science is still evolving, but the overall message for physicians is clear: gambling disorder has biological, psychological and environmental dimensions. Treating it as merely irresponsible behavior can obscure the clinical problem and reinforce the stigma that keeps patients from seeking help.

Start by Asking Questions

Despite the prevalence of gambling, routine screening during medical exams remains uncommon. A 2026 national survey conducted by The Harris Poll for the National Council on Problem Gambling found that 65% of U.S. adults age 21 and older reported participating in at least one form of gambling before age 21. Yet only 15% of adults said they had ever been asked about their gambling behavior by a primary care provider. This represents an important, missed opportunity.

Physicians shouldn’t be expected to conduct an extensive gambling assessment during every visit, but a few straightforward, nonjudgmental questions can open the door. These can include:

• During the past year, have you tried to cut down, control or stop gambling and found that you couldn't?
• Do you spend a lot of time thinking about gambling, planning future bets or figuring out how to get money to gamble?
• Do you often return after losing money to try to win it back?

Have you hidden your gambling or lied to family members, friends or health care professionals about how much you gamble or spend?”

The way the questions are asked matters. A neutral question such as, “I ask all of my patients about behaviors that can affect health, including alcohol, tobacco, drugs and gambling. How often do you gamble?” is less likely to communicate judgment.

If a patient answers yes to one or more questions, the physician does not have to make a definitive diagnosis on the spot. The next step is to explore the behavior further, assess for associated mental health or substance-use concerns and determine whether gambling is affecting the patient's health, finances, relationships or daily functioning. This can be accomplished through a referral to a counselor or certified gambling treatment provider.

Gambling disorder has biological, psychological and environmental dimensions.

Treatment and Recovery

One of the most important messages physicians can convey is that gambling disorder is treatable. Evidence supports approaches including cognitive behavioral therapy and motivational interviewing as the most effective. Treatment should be provided by professionals with appropriate gambling-specific training. Depending on the provider's credentials and scope of practice, treatment may be delivered by certified gambling treatment counselors, licensed mental health professionals and other appropriately trained addiction professionals.

In Minnesota, state-approved gambling treatment providers offer free or low-cost services to eligible residents, and assistance is also available to family members and other people affected by someone's gambling. The Minnesota Department of Human Services supports both outpatient and inpatient treatment.

Minnesota also has a statewide, confidential Problem Gambling Helpline at 1-800-333-HOPE (4673). Treatment information and referrals are available through the helpline, and telehealth services are available through participating providers.

For people with severe gambling disorder, or those who have not been successful in less intensive settings, residential treatment is another option. Minnesota is home to one of the country’s few specialized residential gambling treatment programs, Project Turnabout's Vanguard program in Granite Falls.

For physicians, a referral does not have to be complicated. Providing a patient with the helpline number or connecting the patient with a state-approved treatment provider may be an important first step.

Young People are Particularly Vulnerable

The changing gambling environment also creates a prevention challenge for physicians who care for children, adolescents and young adults. Gambling has moved from casinos and betting parlors into smartphones, social media and video games. Loot boxes, skin betting and other game mechanics can expose young people to chance-based purchasing and gambling-like experiences well before they are legally permitted to gamble.

Research has found an association between loot-box purchasing and problem gambling among adolescents. In one study of Australian adolescents, recent loot-box purchasing remained significantly associated with at-risk and problem gambling even after accounting for conventional gambling participation, age and gender. The researchers cautioned, however, that the study could not establish a causal relationship.

Young people are also developing in an environment of near-constant digital access. Gambling-related content can appear alongside sports, entertainment and social-media feeds, helping normalize wagering as another form of recreation. That makes prevention important. Parents, educators, pediatricians, family physicians and other health professionals can help young people understand that gambling is not an investment strategy and that the ability to make a bet does not mean the bet is financially safe.

A Public Health Response

Treatment is essential, but treatment alone will not address the broader problem. Gambling has become increasingly normalized through its association with professional and collegiate sports, digital entertainment and other mainstream activities. WHO has called for population-level approaches that address gambling availability, marketing, product design, stigma and regulation in addition to treatment.

There is also an important policy dimension. In 2018, the U.S. Supreme Court struck down the federal Professional and Amateur Sports Protection Act, concluding that its prohibition on state authorization of sports gambling violated the Constitution's anti-commandeering principle. The decision left states with substantial authority to determine whether and how to regulate sports betting.

Minnesota remains an unusual case. As of 2026, the state has not established a statewide commercial sports-betting market, although legislation to authorize sports betting has repeatedly been introduced. At the same time, gambling opportunities accessible to Minnesotans extend beyond state-regulated casinos and lotteries, including online and (illegal) offshore platforms.

The policy debate is ultimately a matter for legislators and regulators. From a health perspective, however, physicians have a legitimate role in ensuring that gambling-related harms are part of that conversation.

A Role Beyond the Exam Room

The most immediate opportunity for physicians may be the simplest one —ask questions. Gambling disorder is often hidden, and patients may never volunteer the information. A physician who asks a few routine, nonjudgmental questions can identify a problem that otherwise might remain invisible until it becomes a financial, psychiatric or family crisis.

Physicians can also help reduce stigma by describing gambling disorder as a health condition rather than a moral failing. They can recognize and treat co-occurring depression, anxiety, substance-use disorders and suicidal thinking, while referring patients to professionals with gambling-specific expertise.

Beyond individual patient care, physicians can contribute to prevention and public health efforts by educating colleagues, medical students, patients and families about gambling-related harm. They can participate in community partnerships and help ensure that policymakers understand the health consequences that may not be visible in economic measures of gambling activity.

Gambling itself is not inherently a disorder, and millions of people gamble without developing significant problems. But as gambling becomes more accessible, more heavily promoted and increasingly integrated into everyday life, physicians will encounter its consequences with greater frequency.

Recognizing gambling disorder as a legitimate health issue is an important first step. Asking about gambling, understanding its potential health consequences and knowing where to refer patients can make it easier to identify problems before they become crises. For physicians, addressing gambling disorder does not require becoming an expert in gambling. It requires recognizing that, like alcohol, drugs, tobacco and other behaviors that affect health, gambling belongs in the conversation between patients and their health care providers.

You can learn more about problem gambling by visiting mnapg.org.

Bill Stein, is a contract writer for The Minnesota Alliance on Problem Gambling.