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		Book review [This article prints out to about four pages.] When the Chips Are Down: Problem Gambling in America. By Rachel A. Volberg. (2001). New York: Century Foundation Press, ISBN: 0-87078-469-2 (paperback). Price: US$ 14.00. Reviewed by Henry R. Lesieur, PhD Rhode Island Gambling Treatment Program Rhode Island Hospital Providence, Rhode Island, U.S.A. E-mail: hlesieur@aol.com The book is divided into six chapters: 1. Introduction; 2. What Is Problem Gambling?; 3. Legal Gambling and the Emergence of Problem Gambling; 4. What is the Extent of Problem Gambling?; 5. Addressing Problem Gambling; 6. The Policy Challenges. The book is written in clear prose and is well organized. The introductory chapter is brief (actually the kind of thing you see in a preface) but sets the stage for what follows. The second chapter gives a quick overview of definitional issues (in which problem and pathological gambling are spelled out). The medical and harm reduction approaches to problem gambling are then discussed, followed by a review of some of the individual, family, workplace, financial and legal impacts of problem gambling. A brief account of causal theories of problem gambling is made. This is all information that is useful for neophytes unfamiliar with the issues. The book leaves out youth gambling and a discussion of heavy, non-problematic gamblers. This is a shame as there is some decent research available on both topics. Adolescent gambling has been reviewed by Griffiths and there is an ongoing research program at McGill University worth mentioning. Even a recommendation to look at Griffiths' and Sue Fisher's works in the U.K. would be informative.

		Chapter 3 reviews the evolution and expansion of gambling in the United States. A discussion of opposition forces in the legalization drive and quirks in the American system of legalization (especially with regard to riverboat gambling) is followed by a review of data on the age, gender and ethnicity of gamblers. I found myself wishing that Volberg would speculate beyond the data to explain some of these patterns. For example, blacks are more likely to be weekly gamblers than non-blacks, but less likely to have gambled in the past year. One could speculate that, like patterns of alcohol use and abuse, this may be explained by religious factors. Blacks are more likely to be fundamentalist Christians, thus limiting their overall drinking and gambling. Clearly, further research is needed. Volberg shifts her discussion to changing patterns of gambling frequency in states she has studied. Her conclusion that people increase their gambling when gambling is legalized and then decrease it over time is quite interesting and worthy of note. In particular, Figure 3.2 needs to be examined carefully by those who assume that legalization inevitably means a steady increase in the extent of gambling. The topic of problem gambling emerges in the last four pages of the chapter, primarily in a discussion of the shift in perspective from gambling as "bad" to a perspective sanctioned by the American Psychiatric Association that defines excessive gambling as "sick" behavior. In Chapter 4, the reader confronts technical discussions of different measures of problem gambling like the South Oaks Gambling Screen, SOGS-R (for Revised), and the National Opinion Research Center's Diagnostic Screen for gambling problems (NODS). The rate of problem and pathological gambling and whether it is changing over time (Volberg's answer is that the data are mixed), and the relationship of change to the presence of treatment services, are discussed. This chapter also gives an overview of the risk factors for problem gambling in the general population. In this vein, Volberg does not confine her discussion to individual demographic characteristics but also considers the spread of convenience gambling and event frequency as possible contributors to problem gambling. In particular, there are the potential policy implications of the relationship between legalization of electronic gaming devices and increases in problem gambling among women. In this chapter she relies on data from other countries as well as the United States. She notes that data on the "outflow" of pathological gambling is higher than previously acknowledged. In other words, a substantial per cent of individuals classified as pathological gamblers at one point in time are no longer classified as having a problem at a later point in time. However, the number of individuals with intractable problems may increase. Volberg turns to the issue of addressing problem gambling in Chapter 5. Reading this chapter, it would appear that the casino industry is doing more to raise public awareness of "disordered gambling" (the term the gambling industry prefers) than many state governments. While she points out what is happening in Canada, a more thorough discussion of what has happened in the different Canadian provinces as well as New Zealand and Australia could teach the reader how things could be different if state governments took a more proactive stance. Available treatment is another area addressed. Unfortunately, some of this information is already out of date. For example, Trimeridian no longer operates an inpatient facility. In fact, the failure of different inpatient treatment facilities and the necessity for state funding to support such operations would be a story on its own. Volberg's discussion of treatment evaluations is worth examining. When she turns to research on problem gambling her discussion is narrowly focused on prevalence surveys and funded research. It ignores quite a bit of research conducted outside of those realms. When she comments near the end of the chapter on funding in the U.S. versus Canada and Australia, the paucity of public commitment to addressing the issue in the United States is clear. U.S. funding would have to be increased by 880 per cent (to $.99 per capita) in order to equal the funding level in Australia. Volberg winds up the book by outlining the public policy challenges that lie ahead in the United States. She points out the contrast between the lessons of alcohol and tobacco. While not stating it specifically, in Volberg's view, it appears that the gambling industry has learned to take lessons from both, partially because, as she states, gambling, like alcohol, was successfully medicalized (in the United States in any case). However, when it comes to attempts by specific individuals to sue the industry, they have typically failed. Whether tobacco-like legislation would ever be successful is another matter, primarily because, unlike tobacco, many states actively promote gambling. Her argument that each state should have one regulatory agency to oversee all gambling in the state makes much sense. Instead of having a Lottery Commission, Charitable Gaming Board, Racing Commission and Casino Control Commission, as do many states in the U.S., one agency, a gambling regulatory board would exist. I would add that this agency should have a problem gambling advocate as a member. The board would be able to oversee self-exclusion programs, make sure that fines for violations (either by the gambler or the facility) would go to a problem gambling treatment fund, and would ensure that problem gamblers and their family members were considered in decision-making. The discussion of the scattered approach taken by different federal agencies is quite telling. There is no coordinating agency at the federal level in the United States. Volberg calls for a national clearinghouse for information as well as some agency that would coordinate regulatory efforts and provide help to the states. I would call for the involvement of the World Health Organization in setting up uniform standards like those devised for alcohol; an effort to do just that is being championed in New Zealand. Dr. Volberg's view is clearly that of a sociologist, with both the advantages and drawbacks of that position. While not exhaustive (to do so would require excessive length), the information that is presented is empirically based. There are references for virtually every statement made in the book. Volberg's call for federal involvement, along with her advocacy of a public health perspective that focuses on efforts to keep the social costs down, are features that makes this book a worthy read. This article was not peer-reviewed. Submitted: March 8, 2003 For correspondence: Henry R. Lesieur, PhD Rhode Island Gambling Treatment Program Rhode Island Hospital 235 Plain Street Providence, RI 02905 U.S.A. Phone: (401) 277-0721 Fax: (401) 277-0744 E-mail: hlesieur@aol.com
		issue 9 — october 2003