The paper identifies some major economic, social and environmental effects of gaming-related tourism in Macau, the world’s largest gaming location in respect of casino turnover. The main types of effects of casino development are typically those associated with growth machine theory. The paper also identifies major threats to the sustainable development of Macau as a gaming/tourism destination, arising from a narrow industrial base, competing destinations, community alienation, and what is referred to as the ‘China factor’. The paper discusses the types of strategies that are required if Macau tourism is to counter these threats and develop successfully as a ‘World Centre of Tourism and Leisure’. It is argued that Macau can most effectively achieve this goal if it develops its tourism and gaming industries to be consistent with the key attributes of a creative city.