Gambling, like rust, never sleeps: Neither do the host or environment
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Gambling, like rust, never sleeps: Neither do the host or environment

Professor Max AbbottDirector, Gambling and Addictions Research CentrePro Vice-Chancellor and DeanFaculty of Health and Environmental SciencesAuckland University of Technology9 th European Conference on Gambling Studies and Policy Issues“From Fantasies and Feelings to Facts in the Future”18-21 September 2012Club Hotel Casino LoutrakiLoutraki, Greece

“Science must begin withmyths and the criticism ofmyths” (Karl Popper, 1957)

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

Toxicity‣ General population surveys – cross sectionaland prospective‣ Help-seeking populations

NZ Health Survey 2011-2012

NZ Health Survey 2011-2012

1998 and 2009 Swedish NationalGambling Surveys

Constantly changing‣ To maximise market penetration/revenue‣ New technologies‣ Responding to political and regulatoryenvironment/ changes‣ Responding to consumer and wider changes inpublic behaviour and attitudes

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

Addiction 2005, Vol 100, pp 1219-1239 Orford withcommentaries from Abbott, Blaszczynski, Ronnberg, Room& Shaffer‣ Orford: “Complex and multifactorial though causation is, the more theproduct is supplied in an accessible form, the greater the consumptionand the greater the incidence and prevalence of harm”‣ Abbott: “Most things that go up usually come down. This is also true inepidemiology. Abbott et al (2004b) cite research strongly suggesting thatproblem gambling prevalence will eventually level out and decline, even ifaccessibility continues to increase.”‣ Shaffer: “Observations about gambling-related problems in Nevadaprovide support for the adaptation hypothesis of addiction. That is, afterthe novelty of initial exposure, people gradually adapt to the risks andhazards associated with potential objects of addiction.”‣ Both Abbott et al and Shaffer made earlier reference to adaptation (late1990s)

Working hypotheses – incorporate bothexposure and adaptation models‣ During exposure to new forms of gambling, particularly continuous forms,previously unexposed individuals, population sectors and societies are athigh risk for the development of gambling problems‣ Over time, years rather than decades, adaptation (‘host’ immunity andprotective environmental changes) typically occurs and problem levelsreduce, 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 tomany other continuous forms when exposure is held constant) EGMstypically give rise to more transient problemsRecent reviews indicate that there is support, from a variety of studies, for bothadaptation and exposure hypotheses

Exposure hypothesis - corroborative‣ Problem gamblers – high levels of EGMparticipation/expenditure (clinical presentations andgeneral population surveys)‣ Some studies - higher prevalence in jurisdictions withgreater exposure levels (number of EGMs/EGMexpenditure per capita)‣ Prevalence rates and clinical presentations increased insome groups following increased EGM participation(e.g. women in Australia, NZ, parts of North America)‣ Most studies, high ‘lifetime’ prevalence amongteenagers/young adults relative to adults

Prospective study (Dickerson et al, 2003)‣ Tracked regular EGM players in real-life settings to identify factorsassociated with problem development‣ Most participants lost control over session spend and frequency ofvenue visits – primarily due to number of hours gambling per week‣ Some individual characteristics contributed (non-productivecoping, depression, impulsivity) – but modest impact‣ Most needed to use active and planned strategies to preventlosing control – even then half still lost control sometimes‣ Concluded impaired control and subsequent problemdevelopment “natural consequences of regular, high intensityEGM play.”

Adaptation hypothesis –corroborative 1990’s‣ State/provincial replication surveys divided betweenthose finding higher and lower prevalence rates atfollow-up‣ 1995 and 1999 New Zealand national surveys had lowerrates than 1991 national survey (current rates: 1.1%,0.4%, 0.5%)‣ Australian state/territory surveys and 1999 nationalsurvey (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 regionwith highest gambling expenditure (New England)had lowest prevalence; region with highestprevalence (West) did not have higher expenditurethan other regions

‣ Series of 6 North American replication surveys foundreduced percentage of frequent gamblers despiteincreased per capita expenditure – those withreductions in prevalence had more comprehensiveproblem gambling services‣ 1991-98 NZ prospective study findings challengeassumption that high youth/young adult prevalencemeans increasing problems – two reasons (1) mostolder ‘lifetime’ problem gamblers don’t report havinghad previous problems when reassessed; (2) mostproblems remit, especially if linked with EGMparticipation

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

Productivity Commission (1999)‣ “While causation is hard to prove beyond all doubt,there is sufficient evidence from many differentsources to suggest a significant connection betweengreater accessibility – particularly to gaming machines– and the greater prevalence of problem gambling.”‣ “Determination of the nature of the relationshipbetween the availability of EGMs and gambling-relatedproblems is of central importance to public policy,including government measures aimed at amelioratingproblem gambling.”

Productivity Commission nationalprevalence study (1998)‣ Concluded that EGM density and expenditure have linear relationshipwith prevalence (exposure) – but didn’t provide p values‣ Challenged by Abbott (2001) – suggested that beyond a point (10EGMs per 1,000; $300 per adult) relationship appeared to break down(adaptation) – visual inspection

Storer (2007) independent statisticalanalysis to assess linear and nonlinearrelationshipsNeither supported by data – datainsufficient to assess

Three approaches to examineexposure 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 gamblingavailability across multiple jurisdictions (ProductivityCommission, 1999)‣ Analysis of prevalence rates in relation to bothavailability 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) andprevalence‣Also concluded that “disordered gambling is anapparently robust phenomenon that researchcan identify reliably across a wide range ofinvestigative procedures that vary in quality andmethod”

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

Williams, Volberg & Stevens (2011)‣ ‘standardized’ prevalence estimates examined inrelation 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 PGfor 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 facilitatecomparison of rates between jurisdictions and withinjurisdictions over time

Example: Australia‣ Prevalence rates standardised taking into account differences ininstrument, 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 foravailability hypothesis and adaptation

New Zealand gambling expenditure‣Rapid increase 1994-2003 (EGMs, casinos)‣Stable 2003-2011EGM and venue numbersMachines Venues2003 : 25,000 2,0002011 : 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 ofparticipation – Sweden 1999-2009

Public Health ApproachesObjective – 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) thatinfluence the development of problem gambling‣ Modify host (individual) factors (risk and/or protective) thatinfluence the development of problem gamblingAcceleration of ‘outflow’ (natural/self recovery; interventions) can reduceprevalence, but effect generally minimal at population level“Gambling, like rust, never sleeps

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