Gambling KTE Policy Forum Pantages Hotel Toronto, Ontario March 10 th -11 th Defining & Measuring Harm Alexander Blaszczynski

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1 Pantages Hotel Toronto, Ontario March 10 th -11 th 2016 Defining & Measuring Harm Alexander Blaszczynski School of Psychology, The University of Sydney 10 March 2016 Hosted by

2 Disclosure of interests Financial & professional dealings with the gambling industry & State and Federal governments directly and indirectly over the last three years: Research funding, personal fees for professional consultancy, honoraria for grant reviews & theses examination, royalties for published books, & funding & expenses covered to attend & present at conference & government meetings Gambling industry operators: La Loterie Romande (Switzerland), Svenska Spel (Sweden), Club NSW (Australia), Comelot (UK), La Française des Jeux (France), Loto-Québec (Québec, Canada), Casino Austria, National Lottery (Belgium), Sportsbet, British Columbia Lottery Corporation, Aristocrat Leisure Industries Organisations funded directly or indirectly from gambling industry or levies on gambling industry: Victorian Responsible Gambling Foundation, Ontario Problem Gambling Research Centre, the Responsible Gambling Trust, Manitoba Gambling Research Program, Ministerial Expert Advisory Group (Federal Government), & honoraria & expense reimbursement for training programs & workshops conducted from government funded problem gambling counselling services Government departments or agencies funded by governments: NSW Office of Liquor, Gaming, & Racing, Australian Institute of Family Studies, Gambling Research Australia, Australian Department Social Services Non-industry or non-government agencies: National Association for Gambling Studies, National Council on Problem Gambling, Le Comité d'organisation Congrès international sur les troubles addictifs All professional dealings have been conducted with the aim of enhancing responsible gambling policies & practices, training counsellors, & advancing knowledge of psychology of gambling

3 Inherent tensions Community concerns & harms => regulatory control Restrictivist Prohibitionist Responsible gambling is a contradiction in terms Libertarian Civil liberties paramount Policy outcomes measured by reduction in prevalence rates Harms assumed to be reduced by reduction in prevalence rates 3

4 Irrefutable premise: Excessive gambling causes harm Personal Familial Employment Legal Financial Social 4

5 Absent operational definition Absence of operational measures of direct & indirect harms i. Problem gambling refers to the situation in which a person s gambling gives rise to harm to the individual player, &/or to his or her family, & may extend into the community. (Victorian Casino & Gaming Authority, 1997) iii. Means harm or distress of any kind arising from or caused or exacerbated by, a person s gambling; & includes personal, social, or economic harm suffered by the person, or the person s spouse, partner, family, friends, or wider community, or by society at large. (New Zealand Gambling Act 2003

6 Operational definition: (Langham et al., 2016) Functional definition based on focus, group, interviews with experts & clients i. Any initial or exacerbated adverse consequence due to an engagement with gambling that leads to a decrement to the health or well being of an individual, family unit, community, or population Any: Very broad & non specific Due to engagement: Assumes direct causal relationship Decrement: vague without specifying severity

7 Harm assessed by multiple axes Severity: Minor to substantial (within & across sessions) Upset, discomfort, anger, distress, anguish, angst/pain Chronicity: Isolated, sporadic, or persistent/continuous Nature: i. Affects individual &/or significant others ii. Contained within: personal/family domain (quality of life) external services utilisation: mental health, domestic violence protection, legal, family therapy Impact: Inconsequential transient harm through to serious persistent harms

8 What are the issues? Gambling-related Harms PGSI SOGS NODS DSM-5 Other Gambling disorder prevalence rate Scores used as proxy for harm DSM-5: Jeopardized relationships, job, education or career PGSI: Borrowed money or sold anything to get money to gamble? Gambling caused health problems, including stress & anxiety? People criticised your betting Felt guilty about way you gamble or what happens when you gamble? 8

9 What are the issues? Gambling-related harms PGSI SOGS NODS DSM-5 Other Gambling disorder prevalence rate Scores used as proxy for harm Does PGSI score of 16 indicate twice as much harm as a score of 8? Or increased confidence that the person is a problem gambler? 9

10 PGSI SOGS NODS DSM-5 Other Gambling disorder prevalence rate Scores used as proxy for harm Reduction in prevalence rates assumed to reflect reduction in harms & effective responsible gambling interventions Controversial question: 1. Do all who meet criteria experience harm that requires interventions? 2. Do some who do not meet criteria require treatment 10

11 Prevalence vs Harm Prevalence Instruments: Lane & Sher (2014) NESARC database: multiple measures of harm severity in 22,177 past year drinkers Severe problems experienced by some not meeting criteria Not severe for some meeting criteria we observe that satisfaction of exactly three criteria (i.e., mild AUD) is, in many cases, as severe as satisfaction of a combination of four other criteria. And in many cases the satisfaction of exactly four criteria (i.e., moderate AUD severity) is less severe than satisfaction of exactly three or event two criteria (i.e., mild AUD severity) (p. 8).

12 Policy implications What is required is to enable policies to determine: If strategies to reduce harms in those adversely affected by gambling are effective & not just for those categorised as problem gamblers Concomitantly, if prevalence of problem gambling is reduced but not aggregate community harms If more appropriate allocation of resources to services targeting particular harms can be offered

13 Effectiveness of public health campaigns & treatment interventions for alcohol abuse not assessed by measuring number of individuals meeting criteria for alcohol abuse or dependence Specific harms are targeted: Physical assaults Drink driving Industrial & motor vehicle accidents Hospital admissions (cirrhosis, injuries) Domestic violence Homicides

14 A proposed paradigm shift Case identification Identify specific harms Domestic conflicts Substance abuse Depression/stress Criminal behaviors Debts/bankruptcy Health-related Apply interventions to reduce excessive gambling Outcome measures Changes in targeted harms 1 4

15 Question of causality highly relevant Harmful gambling: Cumulative signs & symptoms reflecting negative effects across multiple domains Critical incidents: Low frequency-high impact diverse discrete events Likely to be mediated by factors external to gambling, & NOT sensitive to change Useful for monitoring but hard to predict Gambling Effect Scale: Preliminary measure designed to assess severity & causality of harms 15

16 Gambling Effect Scale Systematic review of literature delineating domains (or areas of daily functioning) of harm Harm (original n =107 items) Harm (factor analysis) Health Health Leisure activities Leisure Social Social Critical events Critical events Employment & education Financial Financial Psychological harm Psychological harm Low-frequency items excluded or were combined into single item 16

17 1) Health, leisure, critical events, social, employment/education & financial sub-scales classified as effects subscales (indices) 2) The mean of the psychological harm items represented subjective harm (impact) 17

18 Gambling Effect Scale Item: Overall Health Q1. During the past 6 months, my overall health has: Not been problem Been a minor problem in my life Been a moderate problem in my life Been a major problem in my life Permanently deteriorated Q2. Problems with my overall health were: Not related to my gambling Slightly related to my gambling Moderately related to my gambling Strongly related to my gambling Completely related to my gambling Psychological: General happiness Sense of hopelessness Control over life Self respect Frustration Worry 18

19 Clinical sample of n=63 (61% males) PGSI = 18.2; SD: 4.1 Self-reported form of gambling contributing most to problems 6% 5% 6% EGM Track Sports betting Casino 83% 19

20 Harm caused by gambling Weighted means of GES domain composite scores* Health 30 Leisure Critical events Social Employment and Education Financial Psychological *Weighted score: ((Severity)+(Extent)-1))*(Presence)*(Caused) Max weighted mean GES domain composite score =

21 100.00% 90.00% 80.00% 70.00% % of people seeking help by domains of harm* Health Critical event Social 60.00% 50.00% 40.00% 30.00% 31.25% 41.18% 35.00% 47.89% 33.21% Employment and Education Financial** 20.00% 19.05% 10.00% Psychological 0.00% *Leisure was excluded as there are no help seeking items in this domain 21

22 Spearman correlations between sub- & total score of GES with CPGI & NODS CPGI NODS Health * Leisure 0.52* 0.58* Critical Social * Employ/educ Financial 0.62* 0.68* Psychological 0.57* 0.66* GES effects total 0.65* 0.72** 22

23 Top ten gambling related harms by aggregate score: Gambling Effect Scale Items 1. Loss of savings 6. Hopelessness 2. Worry 7. Debt Common harms experienced 3. Unhappiness/depression 8. Restricted leisure pursuits 4. Personal sense of loss of control 9. Relationship conflicts 5. Loss of self-respect 10. Poor sleep 2 3

24 Research findings Harms least commonly endorsed were: 1. Self-inflicted injury & suicide attempts 2. Bankruptcy 3. Eviction/loss of home Diminished quality of life (majority) vs serious/critical harms (minority) - Explains why only 10-30% meeting criteria enter treatment at any time - Severity/impact of harm does not reach threshold for perceived need for treatment - Media campaigns target smallest proportion of gambling disorders 2 4

25 Summary Causal relationships between harm & gambling need to be identified Instruments sensitive to changes in harm need to be developed to supersede reliance on prevalence instruments Media campaigns ought to focus on less severe end of the harm spectrum Normalize help-seeking behavior by avoiding stigmatization (distancing effects associated with fear/negative content) Emphasize improvement in quality of life 25