Alex Blaszczynski PhD

The University of Sydney Gambling Treatment Clinic &

Responsible Gambling Research Group

Gambling-related harm

International Association of Gaming Regulators

2

Gambling environment

• Socio-culture

determines attitudes/acceptance

• Government legislation shapes availability/access

• Industry & media promotion increases attractiveness

• Regulators deal with compliance, crime,

exploitation, & mitigation of harm

• Profit & taxation motives are driving forces

Multiple motivations exist

3

Irrefutable premise: Excessive gambling causes harm

4

Inherent tensions

5

Community concerns & harms regulatory control

Prohibitionist

Responsible gambling

is a contradiction in terms

Libertarian

Civil liberties paramount

Restrictivist

Policy outcomes measured by reduction in prevalence rates

Harms assumed to be reduced by decrease in prevalence rates

Irresponsible gambling practices

6

Irrefutable premise: Excessive gambling causes harm

Familial Personal Employment Legal Financial Social

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Cultural factors

Reported harm: Focus on severe end of spectrum

Personal

Familial

Employment

Legal

Financial

Social

Depression Substance use

Conflict

Divorce

Employment loss

Productivity loss

Bankruptcy

Loss of assets

Offenses

Debts

Health,

welfare &

legal cost

burdens

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Life course &

intergenerational

Cascading

long term

impact of

loss of assets

& relationship

Responsible Gaming Program must rely on two basic principles: Final decision to gamble…

(1) …belongs to the individual

(2) …must be based on informed choice

Governments, regulators, industry & advocacy

groups influence gambling environments

Responsible gambling

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PRIMARY objective of responsible gambling is

to set up policies & practices designed to

prevent & reduce potential harms associated

with gambling (Blaszczynski, Ladouceur, & Shaffer, 2004)

Premise of responsible gambling

• Balance between acceptable levels of harm

& socio-economic benefits while striving for

continued reduction in harm

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Irrefutable premise: Excessive gambling causes harm

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Primary objective is to limit individual’s expenditure

(time & money) to personally affordable limits

Breaching

cultural

expectations

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Responsible gambling achieved through

Information & persuasion Regulation

Knowing when enough is enough!

Player control

Demand control

Behaviour not tolerated!!

Control of player

Supply control

› Policies appear to lack consistency & coherence within

& across national boundaries

› Uncertainty prevails about what we should be trying to

do & how to maximize outcomes

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“Something needs to be done

This is something

Therefore, let’s do it”

Rationale: If we include all possible RG interventions,

we will never be criticized

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What guides regulators in approving applications for

changes to gambling features/environment?

1. Potential (risk) to cause harm (Risk: probability &

consequences)

What metrics do regulators use to evaluate policy

objectives? Reduction in:

1. Incidence Prevalence

2. Reduction in revenue figures

3. Harm caused

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Responsible Gambling as an empirical procedure

- Program only considered responsible if demonstrated

to actually make consumers gamble more responsibly

- The intent to be responsible is not enough

- Extends beyond simple ‘tick-box’ compliance with

regulations

Policies can only be evaluated

if there exist clear objectives

that can be assessed/measured

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I don’t like data,

data makes me insecure

because data are changing all the time,

I prefer opinions,

mainly my opinions,

because my opinions are

Stable,

Permanent

& resistant to any changes in facts….

Let’s avoid thinking like this famous man

who always says….

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› Gambling Disease Kills One Australian a Day, But It's Too

Lucrative to Cure: Slot machines provide billions in revenue at high

social cost. http://www.bloomberg.com/news/articles/2016-09-

27/gambling-disease-kills-one-australian-a-day-but-it-s-too-lucrative-to-

cure

› According to a new report, almost one in four people arrested

in Australia for drug trafficking have a serious gambling

problem. http://www.thecabinsydney.com.au/gambling-addiction-in-

australia-highest-percentage-of-gamblers-in-the-world/

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› Goals & objectives: policies must clearly operationalize

goals & objectives of an initiative

(e.g., precommitment: use or harm minimization?)

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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. Similar to definition used in New Zealand Gambling

Act 2003

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Operational definition: (Langham et al., 2016)

Derived from 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

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Harm assessed across multiple axes

› Chronicity: Isolated or sporadic, or persistent over time (chronic)

› Nature:

i. Affects individual &/or significant others

ii. Contained within: • personal/family domain (quality of life), or

• Involve referral to external services such as mental health services for

depression, domestic violence protection, legal representation, or family

therapy/relationship counselling

› Impact: Outcome of losses can vary from an inconsequential transient

harm through to serious persistent harms

> Severity: Minor to substantial (within & across sessions)

• Upset, discomfort, anger, distress, anguish, angst/pain

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What are the issues?

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?

Gambling-related

harms

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What do prevalence instruments measure?

› Discriminant between different subgroups of gamblers: - Low risk, moderate risk, problem/pathological

› Frequency (sometimes, often, always) but not - Severity

- Direction of causality (pre-existing disorders?)

- Equal weighting for all items

- Low spend &/or infrequent gamblers assumed to be non-problem

gamblers & therefore often not administered screen

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What are the issues?

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?

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What are the issues?

PGSI

SOGS

NODS

DSM-5

Other

Gambling disorder

prevalence rate

Scores used as

proxy for harm

Controversial question:

1. Do all who meet or

not meet criteria

experience harm

that requires

interventions?

Reduction in scores assumed to

reflect recovery

&

reduction in harm

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Prevalence versus harm

Prevalence Instruments:

- Lane & Sher (2014) NESARC database: multiple

measures of severity of harms in a cohort of 22,177

past year drinkers

• Severe harms experienced by some not meeting

criteria

• No severe harms for some meeting criteria

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Prevalence versus harm

Discrepancy between screens & clinical evaluation (r=.48)

- Not all attending treatment exceed threshold scores

(of 258 clients attending University of Sydney

Gambling Treatment Clinic, 52% did not meet formal

DSM criteria)

Conclusion: Spectrum of harms (minor to severe) also

experienced by gamblers not necessarily meeting

diagnostic criteria or threshold scores

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Recalibrate approach to RG

Responsible gambling evaluated by shift in specific

harms rather than prevalence rates

Take away prevalence rates, where is the evidence of

harm found in the community?

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“… lower risk drinkers, by virtue of their sheer numbers, account for

the largest proportion of negative alcohol related consequences in the

population”. (Currie, Miller, Hodgins & Wang, 2014).

It is widely accepted that a large portion of the population experience

harms that, while possibly insignificant at the individual level,

aggregate to a significant cost to the community (Productivity

Commission 2010).

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› Effectiveness of public health policies for alcohol abuse

not assessed by measuring number of cases 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

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A proposed paradigm shift

Prevalence

rates

Identify specific harms: • Relationship conflicts

• Substance abuse

• Depression/stress

• Criminal behaviors

• Debts/bankruptcy

• Health-related

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Reduced demand

& targeted harms

A proposed paradigm shift

Prevalence

rates

Identify specific harms • Domestic conflicts

• Substance abuse

• Depression/stress

• Criminal behaviors

• Debts/bankruptcy

• Health-related

Apply interventions to

reduce excessive

gambling

Outcome measures

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Top ten gambling related harms by aggregate score: Gambling Effect Scale

Items

1. Loss of savings 6. Hopelessness

2. Worry 7. Debt

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

Common harms experienced

1. Self-inflicted injury & suicide attempts

2. Bankruptcy

3. Eviction/loss of home

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Harms least commonly endorsed were:

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

- Are policies driven by the impacts on a minority of problem gamblers?

Responsible gambling initiatives should determine:

• If strategies to reduce harms in those adversely

affected by gambling are effective & not just for those

categorised as problem gamblers

• If prevalence of problem gambling is reduced are

aggregated community harms also reduced?

• If more appropriate allocation of resources to services

targeting particular harms can be offered

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Alex Blaszczynski PhD

The University of Sydney Gambling Treatment Clinic &

Responsible Gambling Research Group

Gambling-related harm

International Association of Gaming Regulators

Challenges

› Operators, regulators & policy-makers often rely on research

data that reports tentative, inconsistent or inconclusive

findings, expressed opinions, or contain methodological flaws

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Two approaches to retrieve RG relevant articles used:

- A systematic search of library databases

- Search targeted period 1962 to October 31, 2015

- 2,548 publications identified

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Examining the quality of evidence

› We excluded 2,496 publications that were:

- In the ‘grey’ literature domain (non-peer reviewed)

- Duplicates

- Not relevant to RG

- Containing insufficient methodological information

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› Used four inclusion criteria:

1) Real gamblers in real environments

2) Included a comparison group

3) Repeated measures &

4) One or more measurement scales

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Only 30 articles met at least one of the four criteria

Only 6 of the 30 articles satisfied all four inclusion criteria

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Content analysis revealed focus on five strategies:

1. Self-exclusion programs

2. Tracking behavioral characteristics or behavior patterns

3. Setting gambling limits

4. Responsible gambling game features, such as warning

messages

5. Staff training

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Conclusion

• Current evidence on effectiveness of RG initiatives is very limited

• Evidence reveals that overall effectiveness & impact of RG activities remains uncertain

• Outcomes assessed by reduction in gambling behaviours, &/or scores on diagnostic instruments, but not in relation to overt harm

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Need to adopt a framework

Responsible policies should emphasize:

- Different stakeholders should work together

- Balance consumer (informed) choice vs consumer

(imposed) protection; liberalism vs paternalism

- Decisions guided by scientific research &

knowledge rather than ideology, politics or opinions

- Ask the correct questions:

• What type & level of harms & its level do we need

to prevent?

• What are the real risk factors that can be modified?

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Online sports betting

Social media: New policies

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Alex Blaszczynski PhD

The University of Sydney Gambling Treatment Clinic &

Responsible Gambling Research Group

Gambling-related harm

International Association of Gaming Regulators