Science must begin with myths and the criticism of myths (Karl Popper, 1957)

Professor Max Abbott Director, Gambling and Addictions Research Centre Pro Vice-Chancellor and Dean Faculty of Health and Environmental Sciences Auckland University of Technology 9 th European Conference on Gambling Studies and Policy Issues From Fantasies and Feelings to Facts in the Future 18-21 September 2012 Club Hotel Casino Loutraki Loutraki, Greece

Agent gambling Many forms Accessed in varying ways/settings Variable toxicity Constantly changing ( never sleeps ) 1980s+ McGambling

Toxicity General population surveys cross sectional and prospective Help-seeking populations

NZ Health Survey 2011-2012

1998 and 2009 Swedish National Gambling Surveys

Constantly changing To maximise market penetration/revenue New technologies Responding to political and regulatory environment/ changes Responding to consumer and wider changes in public behaviour and attitudes

What is the relationship between gambling availability and gambling-related harms? Widely believed increased gambling availability leads to rise in problem gambling More recently proposed individuals and populations adapt and prevalence rates fall Focus of international debate Highly policy relevant

Addiction 2005, Vol 100, pp 1219-1239 Orford with commentaries from Abbott, Blaszczynski, Ronnberg, Room & Shaffer Orford: Complex and multifactorial though causation is, the more the product is supplied in an accessible form, the greater the consumption and the greater the incidence and prevalence of harm Abbott: Most things that go up usually come down. This is also true in epidemiology. Abbott et al (2004b) cite research strongly suggesting that problem gambling prevalence will eventually level out and decline, even if accessibility continues to increase. Shaffer: Observations about gambling-related problems in Nevada provide support for the adaptation hypothesis of addiction. That is, after the novelty of initial exposure, people gradually adapt to the risks and hazards associated with potential objects of addiction. Both Abbott et al and Shaffer made earlier reference to adaptation (late 1990s)

Working hypotheses incorporate both exposure and adaptation models During exposure to new forms of gambling, particularly continuous forms, previously unexposed individuals, population sectors and societies are at high risk for the development of gambling problems Over time, years rather than decades, adaptation ( host immunity and protective environmental changes) typically occurs and problem levels reduce, even in the face of increasing exposure Adaptation can be accelerated by regulatory and public health measures While strongly associated with problem development (albeit comparable to many other continuous forms when exposure is held constant) EGMs typically give rise to more transient problems Recent reviews indicate that there is support, from a variety of studies, for both adaptation and exposure hypotheses

Exposure hypothesis - corroborative Problem gamblers high levels of EGM participation/expenditure (clinical presentations and general population surveys) Some studies - higher prevalence in jurisdictions with greater exposure levels (number of EGMs/EGM expenditure per capita) Prevalence rates and clinical presentations increased in some groups following increased EGM participation (e.g. women in Australia, NZ, parts of North America) Most studies, high lifetime prevalence among teenagers/young adults relative to adults

Prospective study (Dickerson et al, 2003) Tracked regular EGM players in real-life settings to identify factors associated with problem development Most participants lost control over session spend and frequency of venue visits primarily due to number of hours gambling per week Some individual characteristics contributed (non-productive coping, depression, impulsivity) but modest impact Most needed to use active and planned strategies to prevent losing control even then half still lost control sometimes Concluded impaired control and subsequent problem development natural consequences of regular, high intensity EGM play.

Adaptation hypothesis corroborative 1990 s State/provincial replication surveys divided between those finding higher and lower prevalence rates at follow-up 1995 and 1999 New Zealand national surveys had lower rates than 1991 national survey (current rates: 1.1%, 0.4%, 0.5%) Australian state/territory surveys and 1999 national survey (2.1%) substantially lower rates than initial 1991 four cities survey (6.6%)

New Zealand National Surveys (Abbott & Volberg, 1991; 2000)

US national survey (Welte et al, 2002) found region with highest gambling expenditure (New England) had lowest prevalence; region with highest prevalence (West) did not have higher expenditure than other regions

Series of 6 North American replication surveys found reduced percentage of frequent gamblers despite increased per capita expenditure those with reductions in prevalence had more comprehensive problem gambling services 1991-98 NZ prospective study findings challenge assumption that high youth/young adult prevalence means increasing problems two reasons (1) most older lifetime problem gamblers don t report having had previous problems when reassessed; (2) most problems remit, especially if linked with EGM participation

What is the situation in Australia and New Zealand? Australia and New Zealand share history of rapid increase in EGMs Other than WA, widely distributed in clubs and pubs EGM expenditure high (Aus 60%; NZ 50% total) Majority of help-seekers have EGM-related problems

Productivity Commission (1999) While causation is hard to prove beyond all doubt, there is sufficient evidence from many different sources to suggest a significant connection between greater accessibility particularly to gaming machines and the greater prevalence of problem gambling. Determination of the nature of the relationship between the availability of EGMs and gambling-related problems is of central importance to public policy, including government measures aimed at ameliorating problem gambling.

Productivity Commission national prevalence study (1998) Concluded that EGM density and expenditure have linear relationship with prevalence (exposure) but didn t provide p values Challenged by Abbott (2001) suggested that beyond a point (10 EGMs per 1,000; $300 per adult) relationship appeared to break down (adaptation) visual inspection

Storer (2007) independent statistical analysis to assess linear and nonlinear relationships Neither supported by data data insufficient to assess

Three approaches to examine exposure and adaptation: Change over time in single or multiple jurisdictions (Shaffer et al 1997; Williams, Volberg & Stevens 2011) Analysis of prevalence rates in relation to gambling availability across multiple jurisdictions (Productivity Commission, 1999) Analysis of prevalence rates in relation to both availability and time (Storer, Abbott & Stubbs, 2009)

Shaffer et al (1997) Meta-analysis of 120 North American studies Found some support for link between time (used as proxy for gambling access) and prevalence Also concluded that disordered gambling is an apparently robust phenomenon that research can identify reliably across a wide range of investigative procedures that vary in quality and method

Storer, Abbott & Stubbs (2009) Meta-analysis of 34 Australian and New Zealand prevalence studies conducted since 1991 Examined gambling availability (EGMs per capita), time, and prevalence Major findings Strong relationship between increased availability of EGMs (per capita density) and problem gambling (59% total variation) predicts 0.6-1.0 additional problem gamblers per EGM (exposure) Significant relationship between decrease in prevalence and passage of time (18% total variance) when density held constant suggesting annual decrease of 0.14% - 0.04% (mean 0.09%) (adaption) Hypothesis of diminishing rate of problem gambling with increase in EGM density not corroborated (plateauing)

Williams, Volberg & Stevens (2011) standardized prevalence estimates examined in relation to time of study

Data & Approach 187 studies extracted 56 national 27 Australian states/territories 38 Canadian provinces 66 US states Five primary methodological variants Differences in PG assessment instrument & differing thresholds to designate PG for the same instrument Differences in time frame used to assess PG Differences in method of survey administration Differences in how survey is described to potential participants Differences in the threshold for administering PG questions Adjusted estimates take account of variants and facilitate comparison of rates between jurisdictions and within jurisdictions over time

Example: Australia Prevalence rates standardised taking into account differences in instrument, time frame, administration format, survey description & response rates Standardised prevalence rates as a function of survey year represent % of adult population deemed to be PPGM problem gambler (CPGI 5+)

Are prevalence rates going down?

Conclusions Findings provide strong corroboration for availability hypothesis and adaptation

New Zealand gambling expenditure Rapid increase 1994-2003 (EGMs, casinos) Stable 2003-2011 EGM and venue numbers Machines Venues 2003 : 25,000 2,000 2011 : 18,000 1,400

Swedish gambling expenditure Rapid increase 1990s (EGMs) Slight increase 2000-2011 (casinos, internet, state-owned poker website)

Example of changing patterns of participation Sweden 1999-2009

Public Health Approaches Objective health promotion and reduced incidence (new cases/ inflow ) and prevalence (total stock ) Reduce exposure to the agent (gambling) Modify other environmental factors (risk and/or protective) that influence the development of problem gambling Modify host (individual) factors (risk and/or protective) that influence the development of problem gambling Acceleration of outflow (natural/self recovery; interventions) can reduce prevalence, but effect generally minimal at population level Gambling, like rust, never sleeps