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Introduction
Public health initiatives achieved
remarkable successes in the last century, reducing morbidity and mortality
from childhood infectious diseases such as diphtheria and measles; identifying
modifiable risks associated with heart disease and cancer; and promoting
healthy lifestyles and environments. At the beginning of this new millennium,
public health has the opportunity to contribute understanding and solutions
to a range of complex health and social issues that affect the quality
of life of individuals, families and communities. The unprecedented expansion
of legalized gambling is one such challenge that can benefit from a public
health perspective.
In North America during the
early part of the 20th century, most types of gambling were considered
criminal, and legal gambling was highly restricted. Recently, an unprecedented
expansion of legalized gambling has occurred within a new, expanded public
policy framework. The primary driving force behind the explosion of gambling
in North America is the economic necessity of states, provinces and local
governments. Organizations in the United States promote the leisure and
recreational aspects of gambling, whereas in Canada, the social benefits
to charities, non-profit and community service agencies are emphasized
(Campbell & Smith, 1998).
Historically, gambling has
been understood from moral, mathematical, economic, social, psychological,
cultural, and more recently, biological perspectives. Within the health
care field, interest has come primarily from mental health and addiction
professionals. Until recently gambling was not viewed as a public health
matter. (Wynne, 1996; Productivity Commission, 1999; Korn, 2000). The
value of a public health perspective is that it applies different lenses
for understanding gambling behaviour, analysing its benefits and costs
as well as identifying multilevel strategies for action and points of
intervention. note
1 Policy makers,
researchers and practitioners in the gambling field can incorporate a
public health framework to minimise harmful consequences, enhance quality
of life and protect vulnerable people.
Why Use a Public Health Perspective?
A public health approach
incorporates various elements that make it an attractive frame
for addressing gambling issues. It offers
a broad viewpoint on gambling in society —– not focusing solely on individual
problem and pathological gambling. It conceptualizes a range of gambling
behaviours and problems at points along a health-related continuum, which
is similar to the approach taken in alcohol studies.
Public health goes beyond biomedical
and narrow clinical models to address all levels of prevention
note 2 as
well as treatment and recovery issues. It offers an integrated approach
that emphasizes multiple strategies for action and points of intervention
within the health system and community. A public health approach emphasizes
harm reduction note 3 strategies
to address gambling-related problems and decrease the adverse consequences
of gambling behaviour. It addresses not only the risk of problems for
the gambler but also the quality of life note
4 of families
and communities affected by gambling.
Public health action reflects
values of social justice and equity, and attention to vulnerable and disadvantaged
people. Public health professionals often play an advocacy role or act
as a bridge between local citizens and policy makers on particular issues
such as environmental tobacco smoke. One example where they play a similar
role is the issue of government gambling policy acting like a regressive
tax on lower income socio-economic groups.
Public health agencies exist
at municipal, regional, provincial or state and federal levels. They are
well suited to developing surveillance systems to track trends in problem
and pathological gambling as well as the indicators to monitor social
and economic impacts of gambling on communities and population groups.
A public health position recognizes both costs and benefits associated
with gambling. By appreciating the health, social and economic dimensions
of gambling, public health professionals can foster strategies that minimize
the negative effects of gambling while recognizing its potential benefits.
Public Health Foundations
for Gambling
1. Gambling and Health
Public Health embraces the
World Health Organization (WHO) characterization of health as the extent
to which an individual or group is able, on the one hand, to realize
aspirations and satisfy needs and, on the other hand, to change and
cope with their environment (World Health Organization, 1984). Health
is viewed as a dynamic process and as a resource for living rather than
an end in itself. It is a positive concept emphasizing social and personal
resources as well as physical capacities. Building on this broad definition,
gambling can be conceptualized as either healthy or unhealthy.
Healthy gambling entails
informed choice, including an awareness of the probability of winning,
a low-risk pleasurable experience (i.e. legal, safe, regulated) and
wagering sensible amounts. Healthy gambling sustains or enhances a gambler’s
state of well-being. Conversely, unhealthy gambling refers to various
levels of gambling problems. This terminology complements the notions
of healthy people, families and communities.
2. Gambling and Public Policy
During roughly the same period
that gambling was beginning to be seen as health issue in the 1980s
and 1990s, there was a growing interest in healthy public policy.
This expression was embedded in the WHO Ottawa Charter for Health Promotion
in 1986, followed by the Adelaide Statement on Healthy Public Policy
in 1988 (World Health Organization, 1986; World Health Organization,
1988). Healthy public policy refers to the WHO’s thrust that policy
initiatives in every sector should promote health-sustaining
conditions.
In Canada, gambling is regulated
under federal law, the Criminal Code of Canada, adopted in 1892. Only
governments can "manage and conduct" gaming ventures or authorize
charitable gaming under license. Private sector ownership is prohibited.
Over the years, periodic amendments to the sections on gambling have
permitted its growth, but only since the 1970s have lotteries and casinos
been operating legally. In 1985, computer, video and slot devices were
legalized and the provinces were given exclusive control of gambling.
Stakeholder and social policy groups have raised concerns about the
role of government policy in encouraging gambling, while at the same
time, protecting the public interest.
3. Gambling and Public Health
Research
Public health is the study
of the distribution and determinants of health, disease and mortality
in a defined population and the of related public policy measures to
prevent, eliminate or control its occurrence and spread.. Epidemiology
is its central empirical research tool. Prevalence estimates of gambling-related
problems in the general adult population have been carried out in numerous
North America jurisdictions. Fewer epidemiological reports have described
the impact of gambling on vulnerable and specific populations such as
youth, women, older adults and Aboriginal people. To date, no Canadian
national prevalence study of problem and pathological gambling has been
commissioned. There remains a need for research on the incidence of
pathological gambling and longitudinal studies on its natural history
in gamblers.
A review of existing prevalence
studies by the Harvard Medical School Division on Addictions revealed
that 152 gambling prevalence studies have been conducted in North America
as of 1997, including 35 in Canada (Shaffer, Hall et al., 1999). The
estimated lifetime prevalence in the general adult population for problem
and pathological gambling combined (levels 2 and 3 in Harvard study
nomenclature) was reported at 5.5%. There were no significant differences
in prevalence rates between the United States and Canada. Male sex,
youth and concurrent substance abuse or mental illness placed people
at greater risk of a gambling-related problem. Studies carried out by
the United States National Research Council and the National Opinion
Research Center at the University of Chicago as part of the National
Gambling Impact Study Commission generally support these prevalence
estimates (National Gambling Impact Study Commission, 1999; National
Research Council, 1999).
4. Gambling, Public Health
Theory and Practice
The communicable disease
control paradigm of public health is instructive to the gambling phenomenon.
It describes the causal factors and interactions of host, agent and
environment that contribute to a particular infectious disease, such
as AIDS, and the strategies necessary to control its spread (see
Figure 1). This model resembles the addictions
paradigm of drug, set and setting that illustrates the interactions
amongst these components which lead to a particular drug use experience
and a range of possible outcomes (Zinberg, 1984).
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As applied to gambling (see Figure 2),
the model can describe the multiple determinants of gambling problems
and their complex interrelationships (Korn & Shaffer, 1999). The
host is the individual who chooses to gamble, and who may be at risk
for developing problems depending on their neurobiology, genetics, mental
health and behaviour patterns. The agent represents the specific gambling
activities in which players engage (e.g., lotteries, slot machines,
casino table games, bingo, horse race betting). The vector can be thought
of as money, credit or something else of value. The environment is not
only the gambling venue but also the family, socio-economic, cultural
and political context within which gambling occurs (e.g., whether it
is legal, its availability and whether it is socially sanctioned or
promoted). This public health paradigm invites a broad range of prevention
and treatment interventions directed at various elements in the model.
Major Public Health Issues
A public health issue goes
beyond consideration of the individual and their personal health to matters
that affect groups of people who share common characteristics, geography
or interests. The recent, dramatic growth of legalized gambling and its
widespread acceptance raises concerns about its impact on the public's
health and well-being. There are a range of public health issues related
to populations at risk for gambling problems, suffering from gambling
disorders or affected by the gambling practices of others. In addition,
public policy decisions on gambling have implications for communities.
1. Gambling Expansion and
Problem Gambling Trends in the Adult Population
In the last decade before
the millennium, an unprecedented expansion of government-sanctioned
gambling occurred throughout North America. The dominant concern is
the emergence of gambling addiction, which may be stimulated by increased
availability and promotion of casinos, lotteries and VLTs. Currently,
the estimated lifetime prevalence rates for problem and pathological
gambling combined in the general adult population in both the United
States and Canada is low; however, the Harvard meta-analysis of available
studies shows that over the past 25 years there has been a rising trend.
The relationship between
access to gambling and gambling problems is widely debated. A significant
number of replication studies associated with the introduction of new
gambling opportunities in states such as New York, Iowa, Minnesota and
Texas demonstrate an increase in problem and pathological gambling (Volberg,
1995; Miller & Westermeyer, 1996; Volberg, 1996; Wallisch, 1996).
Research done in the United States shows a higher prevalence rate in
states with higher per-capita lottery sales and in areas within 50 miles
(80 km) of casinos (Volberg, 1994; Gerstein, Murphy et al., 1999). These
findings support the general conclusion that gambling expansion is associated
with related to increases in problem and pathological gambling.
2. Youth and Underage Gambling
Youth is a development stage
associated with experimentation, novelty and sensation seeking. However,
the current youth generation is the first to grow up within a society
where gambling is widely available and government sanctioned. The implication
of this societal change for youth gambling behaviour and risk of developing
gambling problems as adults is unclear.
Surveys in Massachusetts,
Minnesota, Nova Scotia and elsewhere point to a high prevalence of problem
and pathological gambling among youth, estimated to be two to three
times higher than in the general adult population (Winters, Stinchfield
et al., 1993; Shaffer, LaBrie et al., 1994; Poulin, 2000). A meta-analysis
showed that the estimated lifetime prevalence for both problem and pathological
gambling in the adolescent study population was 13.3% (14.0% for the
college population), a proportion that has been relatively steady over
the past 25 years (Shaffer, Hall et al., 1997). This high prevalence
of gambling and gambling-related problems among youth, including sports
betting at colleges and universities, is cause for concern and invites
innovative approaches to prevention.
3. The Impacts of Gambling
on Special Populations
A number of special populations
have been identified for focused attention because of their financial
vulnerability, health status or distinct needs. This review of special
populations examines people from lower income socio-economic groups,
women, Aboriginal people and older adults, but it is not inclusive.
Other groups that deserve consideration include ethnocultural minorities,
incarcerated populations, substance abuse and mental health treatment
groups and gambling industry employees. In general, gambling research
within special populations is in an early phase, and these groups deserve
further systematic study before conclusive statements can be made.
-
Socio-Economic Status
There has been considerable
interest in the relation between gambling and socio-economic status.
Recent Statistics Canada reports indicate that although gambling participation
rates and actual expenditures tend to increase with household income,
lower income households spend proportionately more than do higher
income households (Marshall, 1998; Marshall, 2000). For example, in
households in which at least one person was involved in gambling,
those with incomes of less than $20,000 spent an annual average of
$296 on gambling pursuits. This sum represented 2.2% of total household
income, whereas those with an income of $80,000 or more spent $536,
only 0.5% of total income. Given the share of gambling revenue in
Canada and elsewhere that goes to government, these data suggest that
gambling expenditures may be regarded as a voluntary but regressive
tax that has a proportionately greater impact on lower income groups.
-
Women
Women appear to have distinct
gambling behaviours; and they are gambling more now than in previous
years. In the United States, the percentage of women who have ever gambled
rose between 1975 and 1998 from 22% to 82%. In the same period, the
percentage for males increased from 13% to 86% (Gerstein, Murphy et
al., 1999). Female gamblers prefer slot machines, VLTs and bingo to
action table games and horse racing. Compared to males, females gamble
more to escape, reduce boredom or relieve loneliness than for excitement,
pleasure or financial gain (Coman, Burrows et al., 1997).
-
Aboriginal People
Aboriginal Peoples deserve
attention because of the evolution of gaming policy and its potentially
positive economic impact on Aboriginal communities through revenue generation
and employment. At the same time, Aboriginal Peoples may be particularly
vulnerable to the negative impacts of gambling for a variety of complex
health and social reasons.
-
Older Adults
There has been considerable
interest but little empirical research into the gambling behaviour of
seniors who are a sizable and growing proportion of the adult population
(North American Training Institute, 1997; Gerstein, Murphy et al., 1999;
McNeilly & Burke, 2000). Seniors appear to be disproportionately
represented at bingo halls, charitable gaming activities and day excursions
to casinos. Although seniors are generally considered low risk-takers,
there are concerns about their vulnerability to gambling problems springing
from fixed incomes, social isolation and declining health. However,
seniors may also receive health benefits from gambling activity and
its impact on social connectedness. Research that examines the impact
of gambling on depression, physical mobility and quality of life would
enhance our understanding of the risks and benefits of gambling for
seniors.
4. Effects of Gambling on
Family Life
Gambling-related family problems
deserve to be positioned centrally as important public health issues.
A healthy family is integral to developing and sustaining individual self-worth,
meaningful interpersonal relationships, mutual respect and personal resiliency.
Robert Glossop of The Vanier Institute of the Family recently noted, "Families
are perhaps the central determinant of health, the central influence in
the lives of individuals that determine their health status and their
chances of survival" (Avard, 1999). When family members are problem
or pathological gamblers, they can adversely affect their relatives and
significant others. To date, researchers in the gambling field have described
a range of negative health and social consequences for family members
associated with adult disordered gamblers. These effects have been identified
in spouses (Lorenz & Yaffee, 1988), siblings (Lorenz, 1987), children
(Jacobs, Marston et al., 1989) and parents (Heineman, 1989; Moody, 1989).
Family issues include dysfunctional relationships, loss of family income,
neglect, violence and abuse. Both the general public and health professionals
need to be better informed of these potential consequences and elaborate
a full range of family support interventions.
5. Gambling Sites and Community
Quality of Life
When jurisdictions face the
opportunity to establish a gambling facility or expand gambling activities,
there is often extensive, heated community debate regarding the social
costs and economic benefits. Ideally, a community gambling assessment
is shaped by consideration of local community needs, community values,
strategic plans and research findings on community impact. Active participation
of its citizens, involvement of key stakeholder groups and transparent
decision-making are characteristics of a successful community process.
The outcome of this process
should preserve or enhance the quality of community life; sustain or improve
the overall health status of its members; and demonstrate local economic
vitality as a result of either the presence or absence of gambling. Ongoing
monitoring and impact analysis is necessary to evaluate the decision over
time and to make appropriate adjustments.
6. Emerging Gambling Trends
with Public Health Implications
The Internet provides a new
and virtual environment for gambling. It has experienced explosive growth
in the numbers of gambling Web sites, players and revenues (Adiga, 2000).
It is unregulated in North America; operating offshore, it offers sports
betting and casino-style gambling opportunities to individuals possessing
a computer modem and a credit card. It attracts gamblers because it provides
access to gambling activities at anytime in the privacy of their home
or office. Underage gambling is difficult to monitor.
Technology has become a significant
dimension of gambling in general. Concerns have been expressed about the
wide availability and addictive potential of VLTs. On the positive side,
computer- and Web-based technologies can incorporate personal risk assessment
tools for gambling problems, and innovative prevention programs and monitoring
instruments. One type of gambling that has received little attention to
date is gambling that occurs in the financial world. Economic well-being
is a significant determinant of population health. Thus, high risk or
impulsive financial speculation, such as day trading, can have profound
impacts on health status and social institutions.
Creating a Public Health Framework
for Action
What is done to resolve a particular
societal matter depends on how it is framed. Approaching gambling from
a public health perspective offers a strategic vantage point to address
its broad health challenges and inform related public policy.
Three primary principles guide
and inform decision-making. The first is to ensure that preventing gambling-related
problems is a community priority, along with the appropriate allocation
of resources to primary, secondary and tertiary prevention initiatives.
The second is to incorporate a mental health promotion approach to gambling;
one that builds community capacity, incorporates a holistic view of mental
health (including its emotional and spiritual dimensions) and addresses
the needs and aspirations of gamblers, individuals at risk of gambling
problems and those affected by them. The third principle is to foster
personal and social responsibility for gambling policies and practices.
These principles in turn inform
a set of public health goals:
-
to prevent gambling-related
problems in individuals and groups at risk of gambling addiction
-
to promote informed
and balanced attitudes, behaviours and policies towards gambling and
gamblers both by individuals and by communities
-
to protect vulnerable
groups from gambling-related harm.
An action agenda based on these
public health goals and principles has been proposed. note
5
In conclusion, this public
health perspective on gambling issues offers policy makers, researchers,
health practitioners and community leaders a focus for public accountability
and the opportunity to minimize gambling’s negative impacts while balancing
its potential benefits.
References
- Adiga, A. (2000).
- Online gambling poses societal
challenges. Third Harvard International Conference on the Internet
and Society, 2, 9.
Avard, D. (1999).- What does it take to be
healthy? Families Health, 1, 1—2.
Campbell, C.S. & Smith, G.J. (1998).- Canadian gambling: Trends
and public policy issues. Annals of the American Academy of Political
and Social Science, 556, 22—35.
Coman, G.J., Burrows, G.D. & Evans, D.J. (1997).- Stress and anxiety as factors
in the onset of problem gambling: Implications for treatment. Stress
Medicine, 13, 235—244.
Gerstein, D., Murphy, S., Toce, M., Hoffmann, J., Palmer, A., Johnson,
R., Lariso, C., Chuchro, L., Buie, T., Engelman, L. & Hill, M.A.
(1999).- Gambling Impact and Behavior
Study. Report to the National Gambling Impact Study Commission.
Chicago, IL: University of Chicago, National Opinion Research Center.
- Heineman, M. (1989).
- Parents of male compulsive
gamblers: Clinical issues/treatment approaches. Journal of Gambling
Behavior, 5(4), 321—333.
Jacobs, D.F., Marston, A.R., Singer, R.D., Widaman, K., Little, T.
& Veizades, J. (1989).- Children of problem gamblers.
Journal of Gambling Behavior, 5(4), 261—267.
Korn, D.A. (2000).- Gambling expansion in Canada:
Implications for health and social policy. Canadian Medical Association
Journal, 163(1), 61—64.
Korn, D.A. & Shaffer, H.J. (1999).- Gambling and the health
of the public: Adopting a public health perspective. Journal of Gambling
Studies, 15(4), 289—365.
Lorenz, V. (1987).- Family dynamics of pathological
gamblers. In T. Galski. (Ed.) The Handbook of Pathological Gambling
(pp. 71—88). Springfield, IL: Charles C. Thomas.
Lorenz, V. & Yaffee, R. (1988).- Pathological gambling: Psychosomatic,
emotional and marital difficulties as reported by the spouse. Journal
of Gambling Behavior, 4(1), 13—26.
Marshall, K. (1998).- The gambling industry: Raising
the stakes. Perspectives on Labour and Income, 10(4),
7—11.
Marshall, K. (2000).- Update on Gambling. Perspectives
on Labour and Income, 12(1), 29—35.
McNeilly, D. P. & Burke, W. J. (2000).- Late life gambling: The
attitudes and behaviors of older adults. Journal of Gambling Studies,
16(4), 393—415.
- Miller, M.A. & Westermeyer,
J. (1996).
- Gambling in Minnesota. American
Journal of Psychiatry, 153, 845.
Moody, G. (1989).- Parents of young gamblers.
Journal of Gambling Behavior, 5(4), 313—320.
National Gambling Impact Study Commission. (1999).- National Gambling Impact
Study Commission Report. Washington, D.C.: Author.
National Research Council. (1999).- Pathological Gambling:
A Critical Review. Washington D.C.: National Academy Press.
Nechi Training Research and Health Promotions Institute. (1994).- Spirit of Bingoland:
A Study of Problem Gambling among Alberta Native People. Edmonton,
AB: Nechi Training Research and Health Promotions Institute.
North American Training Institute. (1997).- Gambling Away the Golden
Years. Duluth, MN: North American Training Institute.
Poulin, C. (2000).- Problem gambling among adolescent
students in the Atlantic provinces of Canada. Journal of Gambling,
Studies 16(1), 53—78.
Productivity Commission. (1999).- Australia's Gambling
Industries: Final Report. Canberra, ACT: AusInfo.
Shaffer, H.J., Hall, M.H. & Vander Bilt, J. (1999).- Estimating the prevalence
of disordered gambling behavior in the United States and Canada: A research
synthesis. American Journal of Public Health, 89(9), 1369—1376.
Shaffer, H.J., Hall, M.H. & Vander Bilt, J. (1997).- Estimating the Prevalence
of Disordered Gambling Behavior in the United States and Canada: A Meta-analysis.
Boston, MA: Presidents and Fellows of Harvard College.
Shaffer, H.J., LaBrie, R., Scanlan, K.M. & Cummings, T.N. (1994).- Pathological gambling among
adolescents: Massachusetts Gambling Screen (MAGS). Journal of Gambling
Studies, 10(4), 339—362.
Shookner, M. (1998).- The Quality of Life in
Ontario. Toronto, ON: Ontario Social Development Council and Social
Planning Network of Ontario.
Single, E., Conley, P., Hewitt, D., Mitic, W., Poulin, C., Riley,
D., Room, Sawka, E., & Topp, J. (1996).- Harm Reduction: Concepts
and Practice. Ottawa, ON: Canadian Centre on Substance Abuse.
Volberg, R.A. (1994).- The prevalence and demographics
of pathological gamblers: Implications for public health. American
Journal of Public Health, 84(2), 237—241.
Volberg, R.A. (1995).- Gambling and Problem
Gambling in Iowa: A Replication Study. Report to the Iowa
Department of Human Services. Roaring Springs, PA: Gemini Research.
Volberg, R.A. (1996).- Gambling and Problem
Gambling in New York: A 10-Year Replication Survey, 1986 to 1996.
Report to the New York Council on Problem Gambling. Roaring Springs,
PA: Gemini Research.
Wallisch, L.S. (1996).- Gambling in Texas: 1995
Surveys of Adult and Adolescent Gambling Behavior. Austin, TX: Texas
Commission on Alcohol and Drug Abuse. Executive summary available at:
http://www.tcada.state.tx.us/research/gambling/1995/
Winters, K., Stinchfield, R. & Fulkerson, J. (1993).- Patterns and characteristics
of adolescent gambling. Journal of Gambling Studies, 9(4),
371—386.
World Health Organization. (1984).- Report of the Working
Group on the Concepts and Principles of Health Promotion. Copenhagen:
WHO Regional Office for Europe.
World Health Organization. (1986).- Ottawa Charter for Health
Promotion. First International Conference on Health Promotion, Ottawa,
21 November 1986. Copenhagen: WHO Regional Office for Europe. Available
at: http://www.who.int/hpr/docs/ottawa.html
World Health Organization. (1988).- Healthy Public Policy.
The Adelaide Recommendations. Conference statement of the Second
International Conference on Health Promotion, Adelaide, South Australia,
5–9 April 1988. Adelaide, SA: WHO. Available at: http://www.who.int/hpr/docs/adelaide.html
Wynne, H.J. (1998).- Gambling as a Public
Policy Issue. Occasional Paper. Edmonton, AB: Wynne Resources.
Zinberg, N.E. (1984).- Drug, Set and Setting:
The Basis for Controlled Intoxicant Use. New Haven, CT: Yale University
Press.
Acknowledgements
- I express my appreciation
to my colleague Professor Harvey Skinner, Chair, Department of Public
Health Sciences, University of Toronto, for his support and interest
in this work.
-
- This article was peer-reviewed.
-
- Submitted: November 6,
2000
Accepted: February 27, 2001
Figures 1 and 2 used with
the kind permission of the Journal of Gambling Studies © 1999.
David Korn is an addiction
specialist and public health physician. He holds a faculty position
in the Department of Public Health Sciences at the University of Toronto
and maintains a clinical practice in addictions and behavioral health.
Recently he was a visiting professor at Harvard University, Department
of Psychiatry.
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