The Hidden Cost of Sports Betting: A Public Health Crisis in the Making
It’s my pleasure to introduce this guest post by Yeola and Ayers. It is a clever use of data on Sports Betting.
Vinay Prasad MD MPH
When watching the Super Bowl this year, did you notice how different the coverage looked? Gambling was everywhere. The game was played in Caesars Dome, commentators constantly cited the betting lines, and advertisements for sportsbooks filled the airways and internet. If you picked up on it, you’re seeing a much bigger trend.
It all started when the Supreme Court overturned the Professional and Amateur Sports Protection Act in 2018, effectively legalizing sports betting across the United States by offloading their regulation to states. Few could have predicted the magnitude of its impact. What was once confined to a handful of locations has now become a pervasive part of American culture.
In the latest issue of JAMA Internal Medicine we describe the growth in sportsbooks and present what we believe to be the most comprehensive analysis of the relationship between legalized sports betting and public health.
Unprecedented Growth in Sports Betting
Since the 2018 Supreme Court ruling, we document staggering growth in the sportsbook industry. Between 2017 and 2024 sportsbooks expanded from a single state to 38. Concurrently, hundreds of billions of dollars in wagers have been placed, increasing from $4.9 billion in 2017 to $121.1 billion in 2023—94% of them placed online.
Beyond the tremendous scale it is important to keep in mind the context. A study from Southern Methodist University examined 700,000 sports bettors and found that less than 5% of them were winners, despite it being a game of “skill”. In part this is because of the popularity of parlays--bets that combine multiple individual wagers into one. While the potential payout is higher, all bets within the parlay must be correct for the bettor to win, making them highly risky with long odds and little realistic chance of success.
A Public Health Blind Spot
If one wonders what are the public health costs to sports betting, answers are hard to come by.
Despite gambling addiction being recognized in the Diagnostic and Statistical Manual of Mental Disorders, it remains largely overlooked in healthcare and public health with no formal ongoing surveillance. In fact, only 1 of 38 states to legalize sportsbooks even considered gambling addiction and prevention services in the legalizing legalization.
Many people struggling with addiction may not openly discuss it, but they do turn to the internet for answers. By analyzing these online searches, we can assess the scope of gambling addiction problems to fill this data gap—a method we have successfully used before to provide early detection of population health trends, like suicide, which were later confirmed by traditional data.
Record Levels of Gambling Addiction Help Seeking
By analyzing Google search trends from 2016 through mid-2024, we found that searches indicative of a self-diagnosis with or concern about gambling addiction—such as "am I addicted to gambling"—have increased by 23% nationally since the Supreme Court ruling following a delay during the covid pandemic. This corresponds with cumulatively 6.5 to 7.3 million searches nationally.
In states with legal sportsbooks, the opening of any sportsbooks consistently corresponded with increased demand for gambling addiction help-seeking. Illinois (35%), Massachusetts (47%), Michigan (37%), New Jersey (34%), New York (37%), Ohio (67%), Pennsylvania (50%), and Virginia (30%) all experienced significant increases in gambling addiction-related searches following the launch of sportsbooks in their state.
Furthermore, we found that online sportsbooks had about double the impact on gambling addiction help-seeking than brick-and-mortar sportsbooks. For example, in Pennsylvania the introduction of retail sportsbooks led to a 33% increase in gambling addiction help-seeking searches during the five months before online sportsbooks launched. When online sportsbooks became available, searches surged 61%—a significantly greater and more sustained increase that persisted for years, highlighting the amplified risks associated with the accessibility and convenience of online sports betting.
Sportsbooks Need Reform
Meanwhile, the sports betting industry continues to flourish with little to no oversight.
We cannot afford to let the sports betting industry regulate itself. It is time to implement common-sense safeguards to mitigate the public health consequences of widespread gambling access to help the millions already affected and the millions more to come.
1. Sportsbooks should be required to contribute significantly to gambling addiction prevention and treatment.
If you break it, you bought it. Yet, little revenue is being directed to gambling addiction services. New Hampshire legislators dedicated just $100,000 to gambling addiction prevention and support services despite raking in $36.4 million in sportsbook tax revenue during 2023. Allocating a significant portion of sportsbook tax revenues toward addiction services and raising taxes to account for the public health costs offsets is just common-sense.
2. We need stronger advertising regulations, similar to those imposed on tobacco.
Sportsbooks have aggressively marketed themselves, embedding gambling seamlessly into American sports culture. Advertisements flood television broadcasts, social media feeds, and in-game commentary with little limits on what can be said. For example, DraftKing’s advertises sports best as “Risk-Free”, a campaign that triggered a class action lawsuit for misleading consumers. Sensible regulations might include bans on targeting young adults, restrictions on where ads can appear and what claims can be made.
3. Sportsbooks need stricter safeguards
Should online sports betting be allowed at all? Some nations have banned online wagering entirely, while others have implemented technological safeguards to make betting safer. Practical solutions for the United States include imposing betting limits, enforcing mandatory breaks, and banning the use of credit cards for online sports bets. The contrast between these safeguards and the current reality in the states is stark—where it has been alleged that sportsbooks ban successful bettors while catering to problem gamblers, even going so far as to assist those with gambling addictions in obtaining credit cards to keep betting.
4. Implement public awareness campaigns
An advertising counterbalance is needed to make the public aware of potential gambling problems linked to sportsbooks and promote gambling addiction services. These campaigns should highlight the risks of gambling, encouraging early intervention and reducing stigma. We should also invest in evidenced-based messaging rather than doing what feels good, at risk of failing, to doing what actually works. Does a gambling addiction hotline help, what advertisements are most effective, etc. all need scientific answers.
5. We must prepare healthcare and public health to respond to gambling addiction.
Since the legalization of sportsbooks in 2018, only 29 studies, among millions archived by PubMed, mention gambling addiction in their titles. How do we encourage a portion of the public health workforce to address gambling addiction commensurate with the scale of the potential problem? How do we educate health providers about gambling disorder so it can be recognized and treated effectively? In part, sportsbooks could be regulated by public health agencies, in collaboration with gambling agencies, to help guide a response and build these resources.
Act Now Before it's Too Late
It is time for congress to step in. The federal government has largely remained on the sidelines, leaving sportsbooks to states. However, states are actively expanding online gambling from sportsbooks to e-gaming (betting on video games), digital casinos, and poker. Such expansions highlight the inadequacies of states to handle the problem.
The rise of sports betting represents a seismic shift in American gambling culture. If we continue down this path, we risk repeating past mistakes. History has shown that unchecked industries—including addictions like tobacco and opioids—inflict immense harm before regulations catch up. We have an opportunity to act now.
Atharva Yeola is a graduate student studying machine learning and data science at UC San Diego who plans to work on analytics, applied health policy and health informatics in his career; he would like you to know he is currently on the job market. John W. Ayers Ph.D. is a computational epidemiologist focussed on getting the public back in public health via improved surveillance and harnessing technologies for healthcare. He is on the faculty at UC San Diego.
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I dislike sports betting. I consider it a moral hazard regarding the integrity of the competition. You can safely consider me biased in favor of getting rid of it entirely.
OTOH, I'm a bit disturbed that this article comes across as rather unthinkingly authoritarian to me. It is swift to advocate for government infringement on advertising, which is a Free Speech issue, yet makes no attempt to address it as such. It acknowledges that the courts effectively declared this a matter for the States to regulate, yet advocates for the federal government to attempt to intervene anyway. I don't see any respect for individual rights or Constitutional limits taken into account at all. Especially after the severe overreach medical authorities engaged in during COVID (to the great detriment of public health and trust in medical authorities), it's concerning that the lesson doesn't seem to have been learned: 'public health' is NOT a blank check to ignore ethical and legal limits on possible responses.
It's refreshing to read the comments regarding this article. Perhaps it is a sign of the times. Attempting to legislate the morality of a civilization is a slippery slope when individual freedom is impinged upon. The idea that society is injured by an individual's actions leads to the belief that many are responsible for that individual's well being. Our empathy for the individuals hurt by gambling, smoking, alcohol, etc. inexorably leads to calls for limiting individual freedom. On cue, the calls for Congress to save us from ourselves creates a system where the exact people who passed the laws supporting this are now asked to take away another individual freedom to ameliorate their mistake. Have we not learned yet that these supposed saviors are incapable of solutions? Unfortunately, human behavior has no better lesson than to learn the costs of freedom by experiencing the results of it.