Gambling Expansion in North America: A Public Health Perspective

Transcription

1 Gambling Expansion in North America: A Public Health Perspective David Korn, MD, CAS University of Toronto Howard Shaffer, PhD, CAS Harvard University APHA Annual Conference, Philadelphia, Nov 2002 Poly-Drug Use: Multiple Problems, Multiple Challenge Poster Session

2 Poster Abstract During the last two decades of the 20 th century, North America experienced a dramatic increase in legalized gambling. This growth emerged primarily because of governments need to increase revenue without invoking additional taxation. Concern has been expressed about the potential impacts of expanded gambling on quality of life and burden of illness to individuals, families and communities. This poster analyzes gambling from a public health perspective and compares and contrasts the public health experience with addictions and specifically alcohol. Public health has a tradition of addressing emerging and complex health matters that affect the population as well as specific subgroups. The value of a public health perspective is that it examines the broad impacts rather than focusing solely on problem and pathological gambling behavior in individuals. It takes into consideration the wider health, social and economic costs and benefits, and gives priority to the needs of vulnerable people. This poster will examine the public health foundations of epidemiology and disease control and apply these ideas to the gambling phenomenon. The determinants and distribution of gambling problems will be explored and major public health issues highlighted. A framework for public health action will be proposed based on health promotion, disease prevention and harm reduction principles. By understanding gambling s potential impact on the public s health, policy makers, health practitioners and community leaders can frame a balanced strategy that minimizes gambling s negative impacts and optimizes its benefits.

3 PRESENTATION GOALS To increase awareness of an emerging public health issue To share what is known about gambling epidemiology and gambling issues To outline a framework for public health action

4 Public health has had remarkable success with interventions to reduce early death. It has succeeded in removing many morbidity risks Now we must accept the challenge of reducing the risks that compromise quality of life. William H. Foege, MD

5 Gambling Definition Risking money or something of value on the outcome of an event involving chance when probability of winning or losing is less than certain

6 Gambling Definitions Gambling and Public Health: Study of the distribution & determinants of gambling problems in a defined population and the organized measures to prevent, minimize or control its occurrence and spread. Problem Gambling: A progressive disorder characterized by: a) continuous or periodic loss of control over gambling; b) preoccupation with gambling and money with which to gamble; c) irrational thinking; and d) continuation of the activity despite adverse consequences. (Korn DA, Cdn Medical Association Journal, 2000)

7 Gambling Definitions Healthy Gambling: Represents informed choice on the probability of winning, wagering in sensible amounts and a pleasurable gambling experience in low risk situations. Healthy gambling sustains or enhances a gambler s state of well-being. (Korn & Shaffer, 1999) Gambling Addiction: A disorder characterized by gambling preoccupation, irrational thinking about winning, feeling of loss of control, continuation despite adverse consequences (Topp et al., 1998, Canadian Centre for Substance Abuse)

8 Gambling Expansion in North America Dramatic expansion in past decade Increased problem awareness Economic perspective dominant in current political environment

9 U.S. Trends in Gambling Participation Adults gambling increased from 68% to 86% Spending increased from.3% to.74% of personal income Women s patterns grown to resemble those of men U.S. Impact Gambling Study Commission, National Opinion Research Centre

10 Gambling Economy in the U.S. In 1996, gross gambling revenues in the United States were $47.6 billion Greater than combined revenue of film box office, recorded music, cruise ships, spectator sports & live entertainment

11 Value of a Public Health Perspective on Gambling Broad viewpoint on gambling impact Upstream focus Attention to underserved & marginal Engagement of stakeholders Balances health, social, economic costs & benefits

12 A Comparison: Gambling and Alcohol and Drinking Strong industry parallels: heavily marketed, highly regulated, responsible use programs Positioned as an entertainment or recreational pursuit Both prohibited in the 20 th century Limitations on availability Source of tax revenue sanctioned by government

13 Alcohol and Potential Health Benefits Acknowledgement of both risks & benefits of alcohol use as a public health strategy Low level alcohol consumption in older adults reduces mortality from coronary heart disease Guidelines for low-risk drinking: notion of healthy drinking

14 Gambling Addiction Similarities to Substance Abuse: Genetic vulnerabilities Novelty seeking Shifts in neurotransmitters Stigma Differences to Substance Abuse: No chemicals No toxic damage to organs No chemical withdrawal issues

15 Gambling Activity Levels Lifetime prevalence Adults Adolescents College of Gambling 81.19% 77.55% 85.04% Past Year Rates Casino Games Lottery Sports Gambling Non-casino card games Games of skill (Shaffer & Korn, 2002)

16 Harvard Prevalence Study Meta-analysis of 160 North American studies to 1999 Populations: Adult Youth College Treatment-Prison Populations Canadian Journal of Public Health (June 2001)

17 Trends in Past 25 Years Low but increasing levels in general adult population High but stable rate among youth and treatment populations Increased risk in men, youth & institutional populations No significant differences between Canadian & US Harvard Prevalence Study

18 Prevalence Estimates Pathological Gambling (Lifetime) Adult: 1.9 Adolescent: 3.4 College: 5.6 Treatment/Prison: 15.4 (Shaffer & Hall, 2001)

19 Adult Prevalence Rates: A Comparison Difference Pathological Gambling % (Past Year) (Shaffer & Hall, 2001)

20 Comparative Prevalence Rates DISORDER: Past Year Lifetime Pathological & Problem Gambling Alcohol Dependence & Abuse Drug Dependence & Abuse

21 Costs and Benefits of Gambling COSTS Gambling addiction Family dysfunction Substance abuse & mental disorders Suicide Financial difficulties & poverty Criminal behavior BENEFITS Socialization Hopefulness Stress management Local jobs Revenue: government, charity & non profit revenue Aboriginal economic development

22 Public Health Issues Problem gambling trends in adult population Youth gambling Impact on vulnerable and special needs groups Effect on family Impact on quality of community life Balancing costs & benefits

23 Vulnerable Populations Women Older adults Lower socio-economic groups Aboriginal people Ethno-cultural groups Comorbid conditions Homeless

24 Is Pathological Gambling a Discrete Phenomenon? Other Unknown Disorder Manic Episode Pathological Gambling Alcoholism Depression

25 Comorbidity & Gambling Coexistence with other mental disorders: Alcohol & other drug problems Depression & other moods disorders Anxiety & stress disorders Personality disorders Impulse disorders Suicide risk

26 Comorbidity: Alcohol, Smoking & Other Substances - Alcohol is the most commonly abused substance among pathological gamblers - High rate of nicotine use is also very common - Prevalence and severity of pathological gambling increases when more than one substance is abused (Crockford & el-guebaly, 1998) - Genetic risk factors for alcohol dependence and pathological gambling (Shaffer, Hall & Vander Bilt, 1997).

27 Comorbidity: Other Mental Disorders Prevalence of dysthymia, depression, suicidal ideation, and suicide attempts is inflated among disorder gamblers. Anxiety symptoms evident in gamblers who seek treatment Little support for comorbidity and obsessivecompulsive disorder High level of narcissistic personality disorder among pathological gamblers Little information on comorbidity of pathological gambling and other impulse disorders (ie. Attention deficit disorder)

28 Public Health Goals for Gambling PROMOTE informed and balanced attitudes, behaviors and policies PREVENT gambling-related problems PROTECT vulnerable groups from gambling-related harm

29 Framework for Action none Range of Problems mild Range of Behaviors NON- GAMBLING HEALTHY GAMBLING Low Medium High Brief moderate GAMBLING PROBLEMS Treatment severe Intensive Harm reduction Health promotion Primary prevention Secondary prevention Tertiary prevention Range of Interventions

30 Public Policy Concerns Multiple roles of government Advertising and gambling lifestyle Gambling in financial markets Access to & effectiveness of treatment No consensus on public health message Explosion of internet gambling

31 Canadian Public Health Association Initiatives and Action Steps INITIATIVES 1993: Resolution calling for a national health impact assessment of regulated gambling 1999: Resolution related to limitation of video lottery terminals 2000: Adoption of Position Paper: Gambling Expansion as an Emerging Public Health Issue ACTION STEPS ADOPTED Approved public health goals for gambling Endorsed the position that expansion of gambling in Canada has significant health and public policy impacts Convene a public health think tank on gambling Advocate for a national public policy review

32 Public Health Challenges Foster a broad research strategy Monitor gambling advertising Evaluate impact on quality of life Imbed harm reduction Balance the public interest through a national policy review D. Korn, Canadian Medical Association Journal, 2000

33 Conclusions Gambling is an emerging public health issue based on epidemiology, social costs, quality of life concerns Advances in the biological, behavioral and computer sciences will shape the gambling field Gambling represents a central and challenging opportunity for innovative public health interventions, strategic partnerships & new knowledge

34 Resource Material Korn, D.A. Gambling expansion in Canada: Implications for health and social policy. Canadian Medical Association Journal 2000; 163 (1): Shaffer, HJ, Hall MH, Vander Bilt J. Estimating the prevalence of disordered gambling behavior in the United States and Canada: A Research Synthesis. American Journal of Public Health 1999; 89(9): Korn DA, Shaffer HJ. Gambling and the health of the public: Adopting a public health perspective. Journal of Gambling Studies 1999; 15(4): Shaffer HJ, Korn DA. Gambling and Related Mental Disorders: A Public Health Analysis. Annual Review of Public Health 2002; 23: Shaffer HJ, Hall MN. Updating and refining prevalence estimates of disordered gambling behaviour in the United States and Canada. Canadian Journal of Public Health 2001; 92 (3), Korn DA, Skinner H, Gambling Expansion in Canada: An Emerging Public Health Issue. CPHA Health Digest Autumn 2000: 24 (3).

35 Contact Information David A. Korn, MD, CAS Dept of Public Health Sciences Faculty of Medicine University of Toronto Toronto, Ontario CANADA Howard J. Shaffer, PhD, CAS Division on Addictions Harvard Medical School Harvard University Boston, Mass USA Tel: