2012-Prevention of problem gambling.pdf

The general public also accepts the legal restrictions on their unfettered right to own firearms (e.g., restricted access to handguns and automatic weapons), to operate motor vehicles (e.g., need a driving license; mandatory seat belt use; speed limits), and to consume alcohol (e.g., not while driving, only in licensed establishments) despite the fact these restrictions are only really needed for a small minority of people with potential to misuse these products. These are the sorts of limitations that citizens routinely and willingly accept to produce a safer and healthier society overall. 2.1. The Goal of Harm Minimization has to be Given Equal Priority to Revenue Generation. Although many jurisdictions ascribe to these joint goals, very few of them actually achieve it. Most governments with these conflictual goals still have a predominantly commercial orientation, with their ‘social responsibility’ departments having relatively modest influence over overall policy direction. Countries that have enacted legislation that specifically requires gambling venues to detect and deter problem gambling (e.g., Germany, Switzerland) and/or prohibit the pay of gambling operator executives to be tied to gambling revenue (e.g., Germany) have more effectively balanced these goals.

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BEST PRACTICE 3: Employ a Wide Array of Educational and Policy Initiatives. Table 6 indicates that there is almost nothing that is not helpful to some extent and, conversely, there is almost nothing that by itself has huge potential to prevent harm. There is no ‘magic bullet’ to prevent problem gambling. Even total prohibition would likely only have a moderately positive impact, with some offsetting negative consequences. Similarly, even the less effective initiatives may change the behaviour of a few individuals, lay the foundations for later behaviour change, or contribute to the effectiveness of other initiatives. The only caveat to this ‘everything is helpful’ notion concerns situations where the presence of weak initiatives is deemed sufficient, thereby impeding the adoption of more effective ones. This is a very major caveat which applies to many jurisdictions at the current time. The biopsychosocial approach makes it clear that all addictive behaviour, including problem gambling, develops through a complex interaction between many different endogenous attributes and exogenous stimuli with there being a multitude of different risk factors.

Effective prevention of alcohol abuse, for example, has required extensive and pervasive educational and policy initiatives directed at the individual, group and community level (Holder, 2005; Jackson, Geddes, Haw, & Frank, 2012; Slater et al., 2005; Winters et al., 2007). Arguably, the need for comprehensive educational and policy efforts is even greater for problem gambling, as the age of onset tends to be broad in range, not circumscribed to early adolescence as is commonly seen in substance abuse.43 3.1. Recognize that Policy Measures are Equally, if not More Important, than Educational Initiatives. Within the gambling field, sentiments are sometimes expressed that external controls are inferior strategies (e.g., Napolitano, 2003) or that the primary emphasis should be placed on educating gamblers so they can make ‘informed choices’ (e.g., Blaszczynski et al., 2004; Blaszczynski et al., 2008; Blaszczynski et al., 2011). However, jurisdictional approaches to reducing the harm from tobacco, alcohol, motor vehicles, etc. consistently give equal if not higher priority to policy initiatives (i.e., restricting access and operation), so it is unclear why gambling should be limited to just educational initiatives.

Furthermore, research indicates that educational strategies tend to have limited ability to prevent addictive behaviour, and that meaningful policy measures are usually more effective.44 For example, in the substance abuse field a) restrictions on the physical and economic availability of alcohol have been far more effective than educational campaigns in preventing alcohol-related harm (Babor, Caetano, Casswell, et al., 2010; Giesbrecht, 2007; Toumbourou, Stockwell, Neighbors, et al., 2007); b) contingency management approaches in treatment tend to be more effective than counselling (Higgins, Silverman, & Heil, 2007; Prendergast, Podus, 43

This broad range of age onset for problem gambling may narrow with increased time and continued exposure to gambling opportunities. 44

One of the reasons that policy measures tend to be more effective is because of their enduring nature. Educational initiatives tend to be short-term in duration, and consequently, short-term in their effects.

88 Finney, Greenwell, & Roll, 2006); and c) mandated treatment is often as effective as voluntary treatment (Klag, O’Callaghan, & Creed, 2005; Miller & Flaherty, 2002; Stevens et al., 2005; Wild, Roberts, & Cooper, 2002).45 By the same token, the role of education should not be too strongly discounted (e.g, Giesbrecht, 2007) based on its limited effectiveness in awareness campaigns and school-based programs. It is important to remember that a) education and knowledge provides the intellectual context for policy initiatives and likely contributes to their effectiveness (it is not possible to separate out its unique contribution); b) there are some situations in which educational strategies more reliably work (i.e., better quality school-based programs; circumstances outlined in the Health Belief Model; in the context of community mobilization approaches (see below)); c) school-based smoking prevention programs may have beneficial effect over the lifetime of the participants even if they have no apparent effect at schoolleaving age (Jit, 2010); d) erroneous beliefs about gambling are arguably much more common than erroneous beliefs about drugs or alcohol and may well be more directly linked to gambling behaviour than erroneous beliefs about drugs and alcohol being linked to substance use; e) knowledge is often the stated reason for noninvolvement or minimal involvement in

activities such as substance use or gambling; f) treatment works, and most treatment requires a very deliberate and conscious effort to change behaviour based on what the person has learned about themselves and addictive behaviour more generally.

45

With regards to mandatory treatment, what people often fail to remember is that everyone who ‘voluntarily’ presents to treatment has an external reason that motivated them to come (i.e., if they do not change they will lose their spouse, family, health, employment, or freedom). While motivation is essential in therapeutic change, the internal versus external origin of this motivation tends to be less important.

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BEST PRACTICE 4: Coordinate these Multiple Educational and Policy Initiatives. Evidence from allied fields demonstrates that effective prevention requires coordination between a wide range of effective educational strategies and effective policy measures targeting the same outcomes. Multiple prongs within a comprehensive and coordinated prevention strategy are often synergistic, with overlapping initiatives reinforcing the message and power of individual components (Nation et al., 2003; Stockwell et al., 2005). The effect is analogous to a shotgun blast, where the effect of any individual pellet is negligible, but when combined with other pellets aimed at the same target, can collectively have a major impact. To ensure synergistic coordination, it is often preferable to implement initiatives simultaneously rather than sequentially. The greater effectiveness of these more pervasive approaches has been demonstrated both in primary prevention (Durlak & Wells, 1997; and in the treatment of addictive behaviours (Miller, Wilbourne, & Hettema, 2003). It is equally important to ensure that the same core messages are contained across all initiatives. Moreover, educational or policy measures that are misaligned or opposed may negate or even reverse any intended positive impact.

For example, educational messages to “stay within your limit” are undermined by policies that allow ATMs to be placed in close proximity to slot machines, or with loyalty programs that escalate rewards (‘comps’) as losses mount. Furthermore, if the prevention message is that gambling or certain gambling practices is/are potentially dangerous, then it is inconsistent to describe gambling as ‘gaming’, and for commercial advertising to exclusively emphasize how much fun it is and how a big win will improve a person’s quality of life. 4.1 Try to Involve the Local Community in the Implementation of these Multiple Initiatives. Comprehensive approaches that involve mobilizing the entire community tend to be more effective than outside-imposed approaches as it produces more ‘buy-in’ and more people actually involved in implementation and enforcement (Allaman et al., 2000; Casswell, 2000; Holder, Saltz, Grube, et al., 1997; Spinks, Turner, Nixon, & McClure, 2005; Stewart & Casswell, 1993; Toumbourou, 1999; cf. Secker-Walker, Gnich, Platt, & Lancaster, 2002). While the nature and choice of the initiatives should be largely guided by scientific research, the local community is often in a better position to know how to operationalize and enforce these strategies.

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BEST PRACTICE 5: Decrease the General Availability of Gambling. While many factors contribute to gambling participation and the onset of gambling problems, some factors have a stronger relationship than others. Interventions that target these stronger factors are essential components of an overall strategy to prevent problem gambling. One of the more important factors is the overall availability and access to gambling. The strength of the relationship between gambling availability and problem gambling has weakened in the past decade, presumably because ongoing exposure to gambling has helped inoculate the population to the harmful effects (Shaffer et al., 2004; LaPlante & Shaffer, 2007 Williams, Volberg, & Stevens, 2012). Nonetheless, gambling availability continues to be an important contributing factor to problem gambling, particularly for young people who have not had prior exposure, for jurisdictions without extensive prior exposure, and with the introduction of any new form of gambling. While there are a number of ways to achieve lowered gambling availability, those with the greatest empirical support include the following: 5.1 Limit or Reduce the Number of Gambling Venues. There is a positive association between the number of gambling venues per capita (particularly casinos and slot machine venues) and the prevalence of problem gambling.

Furthermore, the causal direction of this relationship is well established from the increase in problem gambling prevalence that typically follows the introduction of new venues. It must be noted that the effectiveness of reducing the number of gambling venues is severely compromised if offset by an increased number of EGMs per venue. 5.2 Limit or Reduce the Number of Different Forms of Gambling. The number of gambling formats a person engages in is a stronger predictor of problem gambling status than is the particular gambling format that is favoured. 5.3 Locate Gambling Venues away from Vulnerable Populations. Individual pre-existing vulnerability to addiction is a strong (perhaps the strongest) determinant of problem gambling. Within most jurisdictions, the greatest preponderance of people with vulnerable attributes (i.e., other addictions, mental health problems, young people) is found in neighbourhoods of lower socioeconomic status. Thus, new venues should not be placed in these types of neighbourhoods. Placing gambling venues in tourist destinations away from major urban centres provides a further safeguard for the local populace, as well as resulting in much better economic benefit because of the out-of-jurisdiction source of the revenue.

Although this strategy partly just shifts the harm to out-of-jurisdiction residents, the actual impact on tourists will be less, as most of these individuals will not be able to regularly patronize the facilities they are visiting, and people with the financial means to travel may have somewhat less personal vulnerability to gambling addiction.

91 5.4 Implement Other Restrictions on Gambling Availability. Several other approaches aimed at reducing gambling availability have the theoretical potential (but little or no existing empirical support) to contribute to an overall problem gambling prevention strategy. A fairly radical strategy utilized on a limited basis around the world involves restricting gambling venue access to non-residents, or drastically limiting the number of gambling venues accessible by residents. Another method with theoretical support is to restrict gambling opportunities (especially EGMs) to dedicated gambling venues rather than allowing additional placement in bars, restaurants, etc. This strategy is defeated, however, if the jurisdiction creates large numbers of gambling venues and distributes them widely among the population. A final approach to reducing gambling availability involves reducing venue hours of operation, a policy measure demonstrated to be effective in reducing alcohol-related harm. The limited empirical support relative to problem gambling prevention may be attributable to the fairly minor reductions in hours of operation that have been implemented to date. Logically, limiting hours of operation targets gamblers whose duration of play is excessive.

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BEST PRACTICE 6: Eliminate, Reduce, and/or Constrain Higher-Risk Forms of Gambling. The most dependency-prone form of gambling tends to be continuous forms with rapid game frequency. EGMs, continuous lotteries, and casino table games epitomize this feature. Eliminating or substantially reducing the numbers of these games would have significant preventative value. Internet gambling is another form of gambling with higher addiction potential because of its 24 hour availability, provision of continuous forms of gambling, and high levels of privacy. It has less potential to cause population-wide changes in problem gambling rates compared to EGMs and other continuous forms of gambling because it tends to be a niche form of gambling that is not well patronized (i.e., although prevalence of Internet gambling has increased significantly since its inception 17 years ago, it is still among the least commonly patronized forms of gambling in most countries). Although prohibition is difficult to enforce, countries with this policy tend to have lower rates of Internet problem gambling relative to countries that have legalized it.

To date, efforts to mitigate the harm of legalized Internet gambling (i.e., through pre-commitment, self-exclusion, and behaviour analytics) have had a modest impact due to the very small percentage of online sites that have adopted these practices as well as the revocable and short-term duration of most of these constraints (Griffiths, 2012; Williams, Wood & Parke, 2012b). 6.1 Constrain EGM Speed, Maximum Bet Size, Maximum Win Size, Frequency of Near Misses, Number of Play Lines, and Seating. To date, the considerable effort that has been put into modifying EGM parameters to reduce their dependency-forming impact has had very limited effect. However, strategies that impose ‘hard limits’ on expenditure, reinforcement frequency, privacy, and comfort have the best potential to minimize harm. (Eliminating bill acceptors also has this ability). 6.2 Require Pre-Commitment of Gambling Expenditure and/or Time on EGMs and Online gambling using Effective Parameters. Pre-commitment is a comparatively new harm minimization strategy that has significant potential for harm minimization. However, similar to other initiatives, it has usually been implemented using ineffectual parameters so as not to inconvenience non-problem gamblers or adversely affect overall revenue.

The degree to which pre-commitment is voluntary , revocable, exceedable, of short duration, available for just some EGMs or some Internet sites, available for just some forms of gambling, and does not use biometric ID or some other form of identification that deters identity swapping, is the degree to which the utility of the technique is primarily limited to non-problem gamblers (which may or may not translate into a decreased future incidence of problem gambling). In contrast, the degree to which all avenues for excessive gambling have been closed, is the degree to which the technique likely has broader utility for problem and non-problem gamblers.

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BEST PRACTICE 7: Eliminate Reward Cards or use them to Foster Responsible Gambling. Traditional Reward/Loyalty cards are incompatible with pre-commitment technologies, as the former rewards amount of play and the latter attempts to constrain amount of play. Thus, they should not be combined in the same card. Furthermore, in jurisdictions with a single gambling provider, there is no justification for Reward cards at all. Rewarding amount of consumption would never be tolerated for alcohol or tobacco, so it is unclear why this would be an acceptable practice for gambling. However, Reward Cards have significant potential to promote responsible gambling if used to reward responsible play, rather than amount of play. For example, players could receive points up to a reasonable operator-set daily level of spending, beyond which they receive no points or start losing points. Another strategy would be for players not being able to collect their player points if they have exceeded their pre-commitment levels. Finally, players could receive points for opting to view educational resources. There is also no reason why the behavioural data from Reward Cards should not be used to proactively alert players to ‘at-risk’ play. If for no other reason, operators having this knowledge and then failing to act on it creates potential legal liability from a ‘duty of care’ perspective.

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BEST PRACTICE 8: Restrict who is Eligible to Gamble. Some people are considerably more prone to gambling addiction than other people (e.g, males; young adults; and people with pre-existing or prior addictions, mental health problems, and conducive personality traits). Furthermore, gambling addiction will have more adverse impacts for some people, and for society more generally, compared to other people (i.e., poor people; citizens of the jurisdiction compared to non-residents). Societal and political constraints will limit the extent to which eligibility to gamble can be selectively applied. However, there can be no doubt about the potentially efficacy of such a targeted approach. The only demographic where there is broadly applied (and accepted) ineligibility concerns prohibition of gambling for youth below the ‘age of majority’. There are both pros and cons to this policy. One pro concerns the fact that adolescents may be neurologically more vulnerable to addictive products compared to adults, with long-term adult ramifications. Another pro concerns the fact that young adults inherently have the highest rates of ‘at-risk’ behaviour, so there is potential utility to delay exposing them to gambling for as long as possible.

Further to this last point, it is almost certain that raising the legal age for gambling (which currently varies from 16 to 25 depending on the type of gambling and jurisdiction), would be a beneficial strategy to minimize gambling-related harm. Prohibition of youth gambling has an important downside, which is that it limits the ability for extended modelling of responsible gambling (i.e., as extended modelling of responsible alcohol use as well as safe operation of a motor vehicle are both known to have significant long-term benefits in reducing harms associated with these products). The absence of healthy modelling undoubtedly contributes to the fact that the highest rates of problem gambling in most Western countries is in the 18-25 year old age group. Hence, modelling responsible gambling to youth prior to their unrestricted ability to gamble themselves would likely have value, as would a graduated ability to gamble independently.

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BEST PRACTICE 9: Restrict the Use of Tobacco and Alcohol While Gambling. Problem gamblers and people at risk for problem gambling are significantly more likely to smoke and to use/abuse alcohol than other people. Accordingly, policies to restrict the use of alcohol and tobacco while gambling have theoretical potential to contribute to a comprehensive preventive strategy. For example, requiring patrons to leave the gambling area to smoke or drink may encourage both gamblers and problem gamblers to take breaks from gambling. Moreover, making alcohol less accessible may reduce the proportion of people who gamble while their decisions are influenced by the disinhibiting effects of alcohol. This may be of particular value when patrons feel the impulse to continue gambling when they reach their limits.

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BEST PRACTICE 10: Restrict Access to Money While Gambling. Research findings (both anecdotal and from survey data) suggest that policies to restrict immediate access to cash (e.g., ATMs) are potentially effective approaches in reducing the degree to which gamblers exceed financial limits. This strategy may be especially significant when considering that gamblers are often in “hot” psychological states as they approach their limits, creating vulnerability to impulsive gambling continuation leading to money losses they cannot afford. The logic here is to create a time buffer between the impulse to obtain more money (the “hot” decision), and acting on the impulse. Thus, ATMs should not be in gambling venues. A related measure is to prohibit gambling venues from offering lines of credit to gamblers. Credit policies do not provide cash with which to gamble; rather, they allow gamblers to accumulate losses up to a pre-negotiated limit. In light of the fact that, by definition, such policies require borrowing money to gamble, there appears to be no defensible rationale for casinos to offer credit to gamblers.

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BEST PRACTICE 11: Impart Knowledge, Attitudes, and Skills to Gamblers to Inhibit the Progression to Problem Gambling. Many of the foregoing Best Practices can best be characterized as “policy measures”. In this sense, policies are official restrictions or controls on gambling that either promote the adoption of risky gambling practices or inhibit the adoption of these practices. In addition to policy measures, however, educational interventions intended to change internal knowledge, attitudes, beliefs, and skills are also important for the prevention of gambling problems. As indicated in the biopsychosocial framework, a person’s knowledge about gambling and the psychological needs served by gambling are among the critical factors that influence both the decision to gamble and the progression to problem gambling. Accordingly, educational interventions with demonstrated ability to change and shape relevant knowledge, attitudes, skills, and practices should be widely offered. Principal settings and resources include primary and secondary schools, colleges/universities, gambling venues, community resources (public health and designated community educational agencies), direct mail (electronic and landbased), and the media (radio, television, the Internet, text messaging, posters, billboards, etc.). 11.1 Increase Knowledge of Gambling and Problem Gambling.

The type of knowledge that is likely to contribute to prevention includes awareness of one’s own gambling profile and the associated risks of excessive involvement. Key knowledge gains need to be achieved in relation to: 1. 2. 3. 4. 5. 6. 7. 8.

The dependency-forming potential of gambling. The signs/symptoms of impaired control/problem gambling. The negative consequences that arise from problem gambling. The true odds of various gambling games. Normative levels of time and money allocations on gambling. 46 Low risk limits or guidelines that predict problem-free gambling. Gambling practices that increase the risk of impaired control and negative consequences. Where to go for help.

This increased knowledge of gambling and problem gambling is particularly important for new gamblers. An educational session for all new gamblers would be one way of accomplishing this. 11.2 Correct Erroneous Cognitions. A particularly important sub-category of change to knowledge/beliefs is the correction of erroneous cognitions common to both gamblers and problem gamblers. Chief among gambling-related erroneous cognitions are the misunderstanding of the independence of random events (i.e., not appreciating the “reload” feature of each play), ignoring the law of large numbers and averages, belief that outcomes can be controlled or predicted, superstitious 46

Normative feedback about alcohol use has been shown to decrease alcohol misuse in university and college students in some circumstances (Moreira, Smith, Foxcroft, 2009).

98 conditioning, and selective memory for wins. Other cognitive errors pertain to motives for gambling. Most common are beliefs that gambling is a valid approach to earning money, and that it is a benign way to seek respite from negative emotions and affect. Faulty cognitions establish an intellectual context or foundation upon which gamblers bet more than they planned or can afford. As such, they are important contributing factors in the development of impaired control, and should be targeted in any comprehensive approach to prevention. A related strategy involves ensuring that such erroneous cognitions are not transmitted or reinforced while players gamble. For instance, certain structural features of EGMs (e.g., the showing of near misses, the use of stop buttons, and the visual dominance of winning symbols while reels are spinning) actively “disinform” players by encouraging them to embrace logical but erroneous perceptions from what they are seeing and experiencing. Reducing or eliminating game features and operating practices likely to foster the adoption of erroneous cognitions, constitutes an important best practice for the prevention of problem gambling. 11.3 Foster Appropriate Attitudes toward Gambling.

The outcomes described in Sections 11.1 and 11.2 are intended to lay the ground work for developing complementary attitudes to further reduce the likelihood of adopting risky gambling practices. Research suggests that the following key attitudes should be considered as outcomes for educational interventions and initiatives: a. Gambling should only come from cash dedicated to leisure expenses that the player can b. c. d. e.

afford to lose. Borrowed money should never be used to gamble. Financial, health and social problems associated with problem gambling can be serious and are worth avoiding. Adopting risky practices and cognitions increases the likelihood of becoming a problem gambler. Increasing benefits from Reward/Loyalty cards are a sign that gambling losses are escalating.

11.4 Foster Skills to Operationalize Behaviour Change. As mentioned, although increases in knowledge and shifts in attitudes may be necessary precursors, they do not ensure behavioural change. One important lesson from allied fields of prevention research is that even when knowledge and attitudinal change is achieved, attendant changes in actual behaviour are much less common. Similar constraints have been found in gambling research with respect to awareness campaigns directed at the general public. A key to achieving behaviour change is to ensure that members of the target group identify and learn appropriate skills to assist them adopt and maintain the desired behaviour change. In this context, skills answer questions about how to apply knowledge and attitudes to the desired behavioural change, and how to overcome obstacles to such change. Some skills will be cognitive (i.e., cognitive coping or cognitive restructuring), others will be behavioural (i.e., behavioural coping), and others yet will involve changes to motivation.

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BEST PRACTICE 12: Keep Prevention Initiatives in Place for a Sustained Period because Population-Wide Behavioural Change takes a Long Time. As indicated earlier, even where comprehensive approaches have been applied in allied fields, immediate effects on behaviour have sometimes been small, or absent. Tobacco use best illustrates this point. There was no dramatic reduction in tobacco use after prevention efforts began in the mid-1960s. Rather, a very slow but progressive decline has been seen over the past 50 years as educational efforts, policies, and public attitudes have coalesced and strengthened. Similar observations apply to the prolonged process of changing drinking practices and lowering the incidence of impaired driving.47 Prevention approaches appear to be mobilizing more quickly with gambling, so there is some possibility that reductions in problem gambling may occur more quickly. Valuable lessons have been learned in allied prevention fields, and there is reason to believe that cohesive strategies for the prevention of problem gambling will develop accordingly. This optimism suggests that the incidence of problem gambling may reduce over a condensed time frame, given the appropriate coalescence of effective educational resources, health-oriented policy, and political will.

Indeed, there is already evidence of a systematic decline in problem gambling prevalence rates in the past 10 years (Williams, Volberg, & Stevens, 2012).

47

Changes in behaviour at a population level are often reflective of changes in society’s norms. Observed moderators are a three-way interaction among health-oriented policies, societal norms, and individual behaviour. In Canada, the National Alcohol Strategy Working Group (2007) has identified a “Culture of Moderation” as the underlying context for a comprehensive prevention strategy. The goal of policy and educational initiatives is to establish as a cultural norm that drinking is a legitimate adult choice, when done in moderation.

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