2012-Prevention of problem gambling.pdf

The program provided information about gambling activities and related misconceptions, social problem solving to resist peer pressure, and excessive gambling. Three months later, students in the Intervention group demonstrated significant improvements in knowledge about gambling and decreased gambling misconceptions relative to the Control group. However, there was no improvement in their social problem solving ability or in actual gambling participation. Encouraging results have been obtained from a high school curriculum in Alberta called “Gambling: A Stacked Deck”. This program was pilot tested in Calgary high schools in 2001/2002 (Davis, 2003; Williams, 2002) and later revised based on the results and feedback from teachers and students. The program consists of a set of 5-6 interactive lessons (minimum 1 hour each) that address the nature of gambling; the true odds and ‘house edge’; signs, risk factors, and causes of problem gambling; and skills for good decision-making and problemsolving. An overriding theme of the program is to approach life as a ‘smart gambler’ by determining the odds and weighing the pros and cons of your actions. The program was administered to 1,253 grade 9 – 12 students in 10 schools throughout southern Alberta, with results compared to 433 students in 4 Control schools.

Three to seven months after receiving the program, students had significantly more negative attitudes toward gambling, improved knowledge about gambling and problem gambling, improved resistance to gambling fallacies, improved decision making and problem solving, decreased gambling frequency, and a decreased incidence of problem gambling (Williams, Connolly, Wood, Currie, & Davis, 2004; Williams, Wood, & Currie, 2010). While the results of this study are encouraging, the program’s ability to sustain its effectiveness over the long-term remains unknown. Moreover, it is sobering to examine literature from other fields (e.g., health promotion, tobacco, drug use, depression, eating disorders). Here, results indicate that even with comprehensive educational approaches, both short and longterm effects on the desired behaviour are often modest (Cuipers et al., 2008); small (Merzel &

24

D’Afflitti, 2003; Pratt & Woolfenden, 2002; Thomas, Baker, & Lorenzetti, 2007; Wandersman & Florin, 2003); or nonexistent (Foxcroft, 2006; Gates, McCambridge, Smith, & Foxcroft, 2006; Giescrecht, 2007; Secker-Walker, Gnich, Platt, & Lancaster, 2002).

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POLICY INITIATIVES Policy initiatives encompass measures intended to prevent problem gambling through the introduction of external environmental controls on the availability and provision of gambling. Policy initiatives can be organized into three categories: restrictions on the general availability of gambling; restrictions on who can gamble; and restrictions on how gambling is provided. As there is considerable evidence on the impact of policy measures, the focus is primarily on research that reports changes in behaviour as measures of effectiveness.

RESTRICTIONS ON THE GENERAL AVAILABILITY OF GAMBLING Increases in the availability of a product are typically related to corresponding increases in use of the product, especially among products or services with dependency-forming potential. Thus, alcohol availability is positively associated with higher levels of consumption, which in turn, is correlated with higher levels of alcohol-related problems (Babor, Caetano, Caswell, et al., 2010; Cook, 2007; Cook & Moore, 2002; Gruenewald, Ponicki, & Holder, 1993; Rush, Gliksman & Brook, 1986; Stockwell & Gruenewald, 2003). A similar relationship exists with illegal drugs (Babor, Caulkins, Edwards, et al., 2010). Similarly, jurisdictions with higher levels of gun ownership have consistently higher rates of gun-related violence (Ajdacid-Gross et al, 2006; Hepburn & Hemenway, 2004; Killias, van Kesteren, & Rindlisbacher, 2001). It is important to note that these relationships are neither perfect, nor simple. For example, there are circumstances where alcohol consumption can decrease despite increases in availability (e.g., Smart & Mann, 1995).

Similarly, the relationship between gun ownership and overall rates of homicide and suicide is less consistent, offering some evidence of a substitution effect (i.e., using other lethal means when guns are not available) (Killias et al., 2001), although this interpretation is contested by some (Hepburn & Hemenway, 2004). Evidence indicates that gambling availability has a similar positive, but complex relationship to problem gambling prevalence. Prior research has documented small but significant withinjurisdiction associations between the availability of gambling and the prevalence of problem gambling (Lester, 1994; National Gambling Impact Study Commission [NGISC], 1999; Pearce, Mason, Hiscock, & Day, 2008; Productivity Commission, 1999; Shaffer, LaBrie, & LaPlante, 2004; Welte, Barnes, Tidwell, & Hoffman, 2009; Welte, Wieczorek, Barnes, Tidwell, & Hoffman, 2004; Williams, Belanger & Arthur, 2011). Furthermore, problem gambling prevalence rates started increasing in North American and Australia beginning in the late 1980s and early 1990s coincident with the most rapid introduction and expansion of EGM and casino gambling in these countries 8 (Williams, Volberg, 8

This period was also coincident with the greatest increase in per capita gambling expenditure, and the introduction of specialized treatment services for problem gambling (In Canada, the first specialized treatment programs for problem gambling were developed in Alberta and New Brunswick in 1993).

26

& Stevens, 2012). However, it is also true that past year problem gambling prevalence rates in most countries peaked in the late 1990s/early 2000s, and there has been a general worldwide downward trend in rates since that time (Williams, Volberg, & Stevens, 2012). Considering that gambling availability has steadily increased in most jurisdictions over the past 30 years, these results provide support both to the contention that increased gambling availability is related to increased problem gambling, as well as the contention that populations tend to adapt over time(Shaffer et al., 2004; LaPlante & Shaffer, 2007; Storer, Abbott & Stubbs, 2009). There are several mechanisms likely responsible for decreasing problem gambling prevalence. They include: a) increased population awareness of the potential harms of gambling (creating less susceptibility); b) decreased overall population participation in gambling (due to greater wariness as well as the novelty having worn off); 9 c) people being removed from the population pool of problem gamblers due to severe adverse consequences deriving from their gambling (e.g., bankruptcy, suicide); d) increased industry and/or government efforts to provide gambling more safely, to enact programs to prevent problem gambling, and to provide treatment resources; and e) increasing age of the population (Williams, Volberg, & Stevens, 2012).

Because there is some relationship between gambling availability and problem gambling prevalence, it comes as no surprise that restricting gambling availability is a policy often used to reduce problem gambling. To this end, total gambling prohibition is one option, and does occur in a few jurisdictions such as Cuba, many Islamic countries10, and the American states of Utah and Hawaii. Discussing the pros and cons of total prohibition are beyond the scope of this paper, and, in any case, most jurisdictions opt for less drastic measures as discussed below.

Restricting the Number of Gambling Venues Most countries require licenses for providers, but do not specify restrictions on the number of bingo halls, horse race tracks, or lottery ticket sales outlets. It is much more common practice, however, to restrict the number of casinos and EGMs. Caps on numbers of casinos and/or gambling houses occur in Austria, Belgium (capped at 9), Italy (capped at 5, the lowest of all 9

There is evidence that the average level of gambling activity in a jurisdiction roughly predicts the jurisdiction’s level of excessive activity or problem gambling (e.g., Chipman, Govini & Roerecke, 2006; Grun & McKeigue, 2000; Hansen & Rossow, 2008, 2012; Lund, 2008). This is known as the ‘single distribution theory’ (Rose, 1985; Rose & Day, 1990), which has been shown to have applicability in predicting rates of problem drinking. Data derived from a recent study by Williams, Volberg & Stevens (2012) confirms that standardized past year rates of problem gambling correlates with the percentage of the population that engages in gambling in both Australian states (Kendall tau b = .28, p = .04 (one-tail), N = 23 pairs) as well as Canadian provinces (Kendall tau b = .30, p = .005 (one-tail), N = 36 pairs). However, worldwide, this relationship is nonsignificant (Kendall tau b = .12, p = .11, N = 54 countries). The failure to find a relationship in this latter case is primarily due to the fact that the highest prevalence rates of problem gambling tend to be found in Asian countries, but the prevalence rate of gambling in Asian countries tends to be relatively low due to low rates of participation by females. 10

Afghanistan, Algeria, Bangladesh, Bhutan, Indonesia, Iran, Jordan, Libya, Mali, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syria, United Arab Emirates, and Yemen (Online Casino Suite, 2012).

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European jurisdictions), the United Kingdom (the highest cap at over 150), the Netherlands, Portugal, Slovenia, and Sweden (European Commission, 2006). A maximum of 40 casinos is allowed in South Africa (National Gambling Board, 2005). In Canada, certain provinces (e.g., British Columbia, Ontario) have capped the number of casinos. Venue caps make theoretical sense considering the positive association between availability and product consumption. Specific evidence of their association with problem gambling is seen in the following:  In the U.S., the National Gambling Impact Study Commission (1999) found that living within 50 miles of a casino is associated with a 50% higher rate of pathological gambling.  Welte, Wieczorek, Barnes et al. (2004) and Welte, Barnes, Wieczorek et al. (2007) independently demonstrated a positive relationship between problem gambling in the United States and the existence of a casino within 10 miles of the gambler’s home.  Lester (1994), in a U.S. wide study, found that the opportunity to gamble at casinos with slot machines, on sports betting, at jai alai, and in teletheatres was associated with living in a state with a greater per capita prevalence of Gamblers Anonymous (GA) chapters.

 In New Zealand, living in a neighbourhood closer to a gambling venue significantly increases the likelihood that that person has gambled and that that person is a problem gambler (New Zealand Ministry of Health, 2008; Pearce et al., 2008).  Shaffer, LaBrie and LaPlante (2004) examined county-level prevalence estimates from the 2000/2001 survey in Nevada in relation to casino availability and found that the four counties with the greatest access to casinos had the highest problem gambling rates, and the four with the least availability had the lowest rates.  Storer, Abbott and Stubbs (2009) conducted a meta-analysis of 34 surveys completed in the Australian states and territories and in New Zealand to examine the relationship between density of EGMs and the prevalence of problem gambling. They found that the prevalence of problem gambling increased with increasing density of EGMs at a rate of about 0.8 problem gamblers for each additional EGM.  Williams, Belanger & Arthur (2011) analyzed data from the 2008 and 2009 Alberta prevalence studies and found that while residential proximity to casinos was consistently and statistically related to problem gambling prevalence, the magnitude of the relationship was small.

 Within Canada, Table 1 presents data demonstrating a significant positive relationship between provincial casino/racino density and provincial rates of problem gambling in 2002. There are also positive relationships between problem gambling rates and the density of bingo licenses and horse racing venues. Interestingly, there is no association with the number of EGM locations, and there is a negative association with the number of lottery outlets.

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Table 1. Correlation between Gambling Venue Density and Canadian Provincial Problem Gambling Prevalence in 2002. Correlation with PG Prevalence

PEI

QU

ONT

NF

NB

BC

NS

AB

SK

MB

Problem Gambling 1 Prevalence

0.9

1.0

1.2

1.3

1.4

1.6

1.6

1.7

2.3

2.4

Casino/Racinos (C/R) per 100000 adults

0

.12

.26

0

0

.59

.27

.77

.94

.46

r = .75* tau-b = .63*

Bingo Licenses per 100000 adults

37

40

22

138

57

N.A.

74

105

230

56

r = .56 tau-b = .44*

1.91

.60

1.11

.24

.68

.65

1.36

2.26

1.21

2.30

r = .40 tau-b = .36

87

62

0

138

111

0

73

50

93

67

r = .01 tau-b = -.07

177

180

113

323

175

128

181

90

104

97

r = - .50 tau-b = -.45*

Horse Racing Venues 2 per 100000 adults # locations EGMs occur outside C/Rs per 100000 adults Lottery Outlets per 100000 adults 1.

2.

As established by a Canadian Problem Gambling Index (CPGI) score of 5 or higher (Note: a score of 5 provides the best demarcation of clinically assessed problem gambling, Williams & Volberg, 2010). The CPGI was administered as part of the Canadian Community Health Survey (1.2) (May – Sept 2002; n = 34,770). Racetracks and Teletheatres.

* Correlation significant at the .05 level (1 tailed) Note. All data come from the Canadian Gambling Digest, published by the Canadian Partnership for Responsible Gambling (2004) and the 2001 Statistics Canada Census. All data from the Canadian Gambling Digest pertains to the period April 2002 to March 2003. Provinces are Alberta (AB), Manitoba (MB), New Brunswick (NB), Newfoundland & Labrador (NF), Nova Scotia (NS), Ontario (ONT), Prince Edward Island (PEI), Quebec (QU), and Saskatchewan (SK).

Before versus after comparisons assessing the impact of the introduction of casinos on subsequent problem gambling prevalence rates is also relevant. A comprehensive review of the 33 studies that examine this issue was recently completed by Williams, Rehm, & Stevens (2011). Overall, 22 studies found that the introduction of a casino was associated with a subsequent increase in problem gambling and/or related indices (i.e., bankruptcies, treatment numbers, suicides, divorces, child neglect), while 11 studies found no impact. An important sub-pattern to these results is that increases in problem gambling and related indices were most likely to be found in studies that examined impacts within a short period of time after the initial introduction of casinos, and less likely to be reported in studies that examined impacts over longer time frames. Similarly, studies finding an impact tended to be conducted during the 1980s and 1990s (a time when gambling was first being introduced), whereas studies failing to find an impact tended to be conducted in the 2000s (i.e., after the populace had already had

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extended exposure to gambling) (Williams, Rehm, & Stevens, 2011). One of the few longitudinal studies in this review (Jacques & Ladouceur, 2006) specifically found a one year effect that had subsequently disappeared after both 2 year and 4 year intervals. Other studies in this review found that increases in problem gambling subsequent to casino introduction only occurred in regions without prior access to a casino, with no impact in regions where casinos were already available (e.g., Blue Thorn Research, et al., 2007).

Restricting More Harmful Types of Gambling Governments commonly adopt policies that prohibit or restrict inherently more “dangerous” or potentially harmful forms of a product. For example, handguns, assault rifles, and automatic weapons are prohibited in many countries, while hunting rifles can be owned legally. Similarly, drugs with greater perceived addictive potential (e.g., cocaine, methamphetamine, heroin) are usually illegal, while psychoactive substances perceived as less harmful are either controlled (e.g., prescription drugs) or legally available but regulated (e.g., alcohol). In the substance abuse field it is well established that there are certain drugs that have a greater harm potential (van Amsterdam, Best, Opperhuizen, & de Wolff, 2004; Nutt, King, Saulsbury, & Blakemore, 2007) and certain alcoholic beverages that bear a stronger relationship with whether a person becomes a heavy drinker (Gronbaek, Jensen, Johansen, Sorensen, & Becker, 2004; Jensen et al., 2002). Under the same principles, it seems reasonable that policies to reduce gambling-related harm should include restrictions on the most dependency-prone forms of gambling. As described below, certain forms of gambling have these characteristics that may warrant greater restriction. Even so, it is also important to recognize that addicts tend to be versatile in the products they consume.

Although problem drinkers often have a preferred beverage, they nonetheless consume a wide range of alcoholic beverages. Similarly, drug abusers usually consume a wide range of substances in addition to the one that is causing the most problems. Hence, it should not be surprising to find that 44% of all problem gamblers in Alberta reported there was no particular form of gambling most responsible for their problems in the 2008 and 2009 Alberta prevalence surveys (Williams, Belanger, & Arthur, 2011). In a separate study, Wood & Williams (2011, 2012) found that 42% of Canadian Internet problem gamblers and 46% of international Internet problem gamblers reported there was no particular form of gambling (either landbased or online) that contributed to their problems more than others. Continuous Forms of Gambling From a theoretical perspective, forms of gambling that can be played quite rapidly and that provide a high frequency of reinforcement (‘continuous forms’) should be the most problematic (Parke & Griffiths, 2007; Welte, Barnes, Wieczorek, Tidwell, & Hoffman, 2007). This is analogous to drug addiction, where speed of effect (e.g., injection or inhalation versus

30

ingestion) and drug half-life are potent determinants of the dependency-forming potential of different substances (Nutt et al., 2007). Automated “electronic gambling machines (EGMs)” (i.e., slot machines, video lottery terminals (North America); fixed odds betting terminals, fruit machines (U.K.); pokies (Australia); pachinko (Japan); electronic bingo machines, etc.) epitomize continuous play and are the form of gambling most often identified by problem gamblers, treatment agencies, and gambling researchers in Western countries as creating the most problems (e.g., Dowling, Smith, & Thomas, 2005; Brooks, Ellis, & Lewis, 2008; Meyer, Hayer, & Griffiths, 2009; Williams, Volberg, & Stevens, 2012) (see also Welte, Barnes, Wieczorek et al., 2007; Welte, Wieczorek, Barnes et al., 2004). Two other forms of continuous gambling with a greater theoretical propensity for addiction are casino table games and ‘continuous’ lotteries. EGMs are essentially lottery machines that initiate a new draw with every play or spin. ‘Continuous lotteries’ have a draw every few minutes throughout the day (e.g., ‘electronic keno’, ‘Rapido’) are slower variants on this and theoretically have correspondingly similar addictive potential. ‘Rapido’ has a documented association with problem gambling in France (Valleur, 2009).

Casino table games (e.g., baccarat, blackjack, roulette, craps) are another type of gambling with continuous play and a high frequency of reinforcement. These games (particularly baccarat) are often identified as the most problematic form of gambling in Asian countries (Ka-Chio Fong & Orozio, 2005; Tang, Wu, & Tang, 2007; Teo, Mythily, Anantha, & Winslow, 2007; Wong & So, 2003; Williams, Volberg, & Stevens, 2012) and also tend to have an elevated association with problems in Western countries (Welte et al., 2007; Williams, Volberg, & Stevens, 2012). Table 2 illustrates the strong association between EGM and casino table game density with Canadian provincial problem gambling prevalence in 2002. (Note: problem gambling is established by a Canadian Problem Gambling Index (CPGI) score of 5 or higher, as this provides the best demarcation of clinically assessed gamblers, Williams & Volberg, 2010. The CPGI was administered as part of the Canadian Community Health Survey (1.2) (May – Sept 2002; n = 34,770). Game density data pertains to the period April 2002 to March 2003 and comes from the Canadian Gambling Digest, published by the Canadian Partnership for Responsible Gambling (2004)).

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Table 2. Correlation between Game Availability and Canadian Provincial Problem Gambling Prevalence in 2002. Correlation with PG Prevalence

PEI

QU

ONT

NF

NB

BC

NS

AB

SK

MB

Problem Gambling Prevalence

0.9

1.0

1.2

1.3

1.4

1.6

1.6

1.7

2.3

2.4

EGMs per 100000 adults

388

341

213

633

433

102

591

471

758

807

r = .66* tau-b = .45*

Casino Table Games per 100000 adults

0

3.6

5.9

0

0

12.1

7.6

17.5

13.6

7.8

r = .62* tau-b = .58*

* Correlation significant at the .05 level (1 tailed). Provinces are Alberta (AB), Manitoba (MB), New Brunswick (NB), Newfoundland & Labrador (NF), Nova Scotia (NS), Ontario (ONT), Prince Edward Island (PEI), Quebec (QU), and Saskatchewan (SK).

This same strong relationship between EGM density and regional rates of problem gambling has been documented in Australia (Productivity Commission, 1999; South Australian Centre for Economic Studies [SACES], 2005; Storer, Stubbs, & Abbott, 2009). Table 3 illustrates the relationship for the year 1999 (last time a national survey was conducted in Australia). (Note: problem gambling prevalence established by a South Oaks Gambling Screen (SOGS) score of 5 or higher. The SOGS was administered in 1999 to a sample of 10,525. EGM data comes from the 1999 World Count of Gaming Machines (Taylor Nelson Sofres, 1999). Note also that # of people per EGM used in this table is the inverse of EGMs per person). Table 3. Correlation between EGM Availability and Australian State/Territory Problem Gambling Prevalence in 1999. TAS

WA

QLD

NT

ACT

VIC

SA

NSW

Problem Gambling Prevalence

.44

.70

1.88

1.89

2.06

2.14

2.45

2.55

# People per EGM

198

1576

116

158

71

158

117

71

Correlation with PG Prevalence

r = -.60 (p = .06) tau-b = -.52*

* Correlation significant at the .05 level (1 tailed). Tasmania (TAS), Western Australia (WA), Queensland (QLD), Northern Territory (NT), Australian Capital Territory (ACT), Victoria (VIC), South Australia (SA), New South Wales (NSW).

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Across countries, however, the association between a country’s EGM density and their standardized 11 problem gambling prevalence rate is in the opposite direction (Kendall tau b = -.18, p = .03, 1 tail, 55 pairs). Table 4 documents this relationship using data taken from Williams, Volberg & Stevens (2012). One thing that weakens this association is that some of the highest problem gambling prevalence rates occur in Asian countries with low EGM densities (casino table games and sports betting are stronger correlates of problem gambling in these jurisdictions). Another is the fact that the lowest problem gambling prevalence rates tend to occur in European countries which often have high densities of EGMs, but with much lower bet and win sizes compared to other countries. Table 4. Worldwide Relationship between EGM Availability and Standardized Problem Gambling Prevalence.

Jurisdiction

Year

Netherlands Denmark Norway Germany Germany Germany Norway Great Britain Germany Norway Great Britain Germany South Korea South Korea New Zealand Switzerland New Zealand Iceland Hungary

2004 2005 2008 2006 2009 2007 2002 2007 2011 1997 1999 2009 2011 2007 1999 2005 2007 2007 2007

Standardized Past Year Problem People per EGM Gambling Prevalence .50 2579 .50 286 .50 5000012 .60 407 .61 388 .62 407 .70 150 .70 223 .75 388 .80 155 .80 236 .84 412 .84 32796 .90 36878 1.00 255 1.00 659 1.00 197 1.00 280 1.00 304

11

Williams, Volberg & Stevens (2012) have produced standardized rates of problem gambling for all jurisdictions by using the original obtained rate and then adjusting for: the specific assessment instrument, time frame used, administration format, and survey description. 12

Arbitrarily set to 50,000 (i.e., the highest value in the column) as there were no EGMs in these jurisdictions in that year.

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Jurisdiction

Year

Germany France Germany Canada New Zealand Iceland Norway Great Britain Norway Sweden United States Sweden Finland Estonia United States Norway Canada Finland Estonia Canada Italy Switzerland Finland Belgium Singapore N. Ireland Singapore Australia Hong Kong United States Hong Kong Singapore Macau South Africa Hong Kong

2011 2010 2009 2002 2004 2005 2008 2010 2010 1998 2003 2009 2011 2004 1998 2005 2007 2003 2006 2000 2008 1998 2007 2006 2010 2010 2008 1999 2011 2000 2005 2005 2003 2008 2001

Standardized Past Year Problem People per EGM Gambling Prevalence 1.00 388 1.09 3657 1.13 412 1.20 436 1.20 158 1.20 280 1.23 5000012 1.30 251 1.35 1686 1.40 1114 1.50 426 1.50 1017 1.50 271 1.60 990 1.70 468 1.70 151 2.00 377 2.10 338 2.10 1182 2.20 570 2.30 291 2.40 834 2.40 277 2.80 384 3.10 2351 3.30 457 3.50 2277 3.90 105 4.40 5000012 4.60 468 4.80 5000012 4.90 2433 6.00 550 6.40 2075 7.60 5000012

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EGMs are prohibited or not available in many jurisdictions. The World Count of Gaming Machines reports that EGMs were not available in 40% (94/235) of countries in 2010 (32/51 Asia-Pacific countries, 0/2 North American countries, 13/50 Central and South American countries, 23/75 European and Middle Eastern countries, and 26/57 African countries (Taylor Nelson Sofres, 2011). In Canada they are available in all 10 provinces, but not in the territories of Nunavut or the North West Territories. In the United States they are available in 38 states, but not currently in Arkansas, Georgia, Hawaii, Kentucky, Massachusetts, New Hampshire, Ohio, South Carolina, Tennessee, Utah, Vermont, or Virginia (American Gaming Association, 2012)13. In Australia they are available in all states and territories. In Europe they are currently available in all countries except Andorra, Greenland, Liechtenstein, San Marino, and Vatican City (Taylor Nelson Sofres, 2011). There is some empirical evidence regarding the impact of EGM bans in two American states: South Dakota and South Carolina. In 1994, South Dakota’s 7,859 legal EGMs were declared unconstitutional, shut down for three months, and then reinstated by public referendum. In the 11 months prior to the ban, 4 substance abuse treatment centres averaged 68 inquiries and 11 problem gambling clients per month.

During the shutdown, there were only 2 inquiries and 2 people treated among all four centres. In the 3 months after EGM reinstatement, the centres averaged 24 inquiries and treated 8 gamblers per month (Carr, Buchkoski, Kofoed, & Morgan, 1996). In 2000 the 36,000 legal EGMs in South Carolina were banned. Following the ban there was a significant increase in seizures of illegal machines, from 48 in 2000-2001 to 1,551 in 2004-2005 (South Carolina Law Enforcement Division, 2005). Nonetheless, the number of active Gamblers Anonymous groups fell from 32 to 16 within 90 days of the shutdown, with several of the remaining active groups reporting the size of their group meetings decreasing from 40 to 1 or 2 (Bridwell & Quinn, 2002). Additionally, the most active gambler’s hotline in the state reported that calls fell from 200 a month to zero. These reductions have been maintained in subsequent years. Current directory information for Gamblers Anonymous (2012) lists 7 active GA groups in South Carolina, a drop from 10 active groups in 2006 (Gamblers Anonymous, 2012). In another “natural experiment,” the Norwegian government instituted a complete ban on 12,000 privately controlled slot machines in July 2007 as part of a move toward replacing these EGMs with government controlled EGMs in January 2009.

When the ban was implemented, the number of calls to the national helpline fell by 38% and treatment seeking was reduced by 52% (Engebø & Gyllstrøm, 2008). A prospective study of 1293 EGM gamblers found that 4 months after the ban there was a significant reduction in problem gambling (primarily among men), EGM gambling, as well as participation in most other forms of gambling (primarily among low intensity gamblers) (Lund, 2009). There was, however, a small but statistically significant increase in participation in Internet gambling, from 22.6% to 25.4% (Lund, 2009). Similarly, 13

Georgia has 2 riverboat casino cruises and South Carolina has 3. Small numbers of ‘instant racing machines’ are available in Arkansas and Kentucky (Aug 2011). These are machines that offer wagering on historic horse races. Georgia has 2 riverboat casino cruises and South Carolina has 3.

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population surveys by the organization SINTEF in 2007 (before the ban) and 2009 (after the ban had ended) found that half of slot machine users either significantly reduced or completely ceased to gamble for money (Øren & Leistad, 2011). It appears that reductions in EGM numbers do not have a significant impact if they do not substantially change overall EGM availability. A study by South Australian Centre for Economic Studies (2005) investigated the impact of regional restrictions on EGM numbers in the state of Victoria. Findings indicated that gambler losses were not generally reduced, help-seeking by problem gamblers did not change, and there were no sustained revenue losses in venues where machines had been removed. However, the authors pointed out that the areas with new caps tended to be areas with the highest EGM per capita ratios to begin with, and the magnitude of the reductions was small. Similarly, a 15% reduction in the number of EGMs in South Australia found very little evidence of behavioural changes or reduction in EGM revenue (Delfabbro, 2008). A 25% reduction in EGMs outside casinos (‘video lottery terminals’) in Nova Scotia, Canada in November 2005 is said to have resulted in a relatively small reduction in revenue (Flinn, 2006).

Internet Gambling Theoretically, Internet gambling should also have a higher risk potential because of its 24 hour accessibility (anything that significantly increases gambling availability significantly increases risk) in conjunction with its provision of online forms of continuous gambling (e.g., Meyer, Fiebig, Hafeli, & Morsen, 2011). The the ability to play while intoxicated, the enhanced privacy it offers (see EGM Privacy section), and the lack of responsible gambling practices on the majority of online sites represent additional contributing factors (Griffiths, 2012; Williams, Wood & Parke, 2012a; Wood, Williams & Parke, 2012). Indeed, Internet gamblers have significantly higher rates of problem gambling compared to non-Internet gamblers (Williams & Wood, 2007a; Wood & Williams, 2007a, 2007b, 2009; Wood, Williams & Parke, 2012).

However, it has been pointed out that this relationship exists primarily because problem gamblers are versatile gamblers who tend to engage in a wide variety of gambling formats that will often include Internet gambling (Wood & Williams, 2009; Wood, Williams & Parke, 2012).14 The association between Internet gambling and problem gambling is usually nonsignificant when controlling for number of gambling games engaged in (Halme, 2011; LaPlante, Nelson, LaBrie, & Shaffer, 2009; Vaughan-Williams, Page, Parke, & Rigbye, 2008; Welte, Barnes, Tidwell, & Hoffman, 2009). However, cross sectional analysis does not disentangle the temporal course of events that may differentiate online gambling from other forms (i.e., although gamblers add many different forms of gambling on their path to problem gambling, the addition of certain forms (e.g., 14

Problem gamblers appear to adopt all new forms of gambling more quickly than nonproblem gamblers. For example, the newest forms of gambling in the United Kingdom (‘spread betting’ and ‘fixed odds betting terminals’) had the highest association with problem gambling in the 2007 U.K. prevalence survey (Wardle et al., 2007).

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Internet gambling) may be more likely to immediately precipitate disordered gambling compared to other forms). Longitudinal analysis is the only way of disentangling such issues. The limited existing longitudinal evidence shows that although many problem gamblers gravitate to Internet gambling, a more common pathway is for Internet gambling to precede the development of problem gambling or for it to develop simultaneous with problem gambling (Wood, Williams & Parke, 2012). Several countries explicitly prohibit most or all forms of online gambling. These include Bermuda, Cambodia, China, Cuba, Germany, Greece, India, Malaysia, Romania, South Africa, and the Ukraine (Williams, Wood, & Parke, 2012a).15 However, a more common approach is for countries to place restrictions on Internet gambling. For example, many countries allow certain forms (most typically online lotteries, instant lotteries, sports betting, and horse racing) and make other forms illegal (most typically, casino games). This occurs in: Australia, Belgium, Brazil, Canadian provinces, Chile, Czech Republic, Denmark, Finland, France, Hong Kong, Hungary, Iceland, Israel, Italy, Japan, Latvia, Liechtenstein, Lithuania, Luxembourg, Macau, Netherlands, New Zealand, Norway, Poland, Portugal, Russia, Singapore, Slovenia, South Korea, Sweden, Switzerland, Taiwan, and the United States.

Several jurisdictions allow participation in online gambling from domestic sites, but prohibit accessing online gambling located outside the country (Austria, Belgium, Denmark, Estonia, France, Germany, Hong Kong, Hungary, Israel, Italy, Norway, Slovenia, South Korea, and the United States). Some countries go further and restrict patronage of domestic online sites to residents only (Austria, Canadian provinces, Finland, Philippines). Finally, a few countries permit online gambling, but prohibit their own residents from accessing these sites (e.g., Australia for online casinos, Malta, Papua New Guinea) (Williams, Wood, & Parke, 2012a). There are three primary legal approaches to limiting illegal online gambling. The most common approach is legislation which prohibits consumers from participation (whether it be any form of online gambling or accessing foreign online gambling sites) (Williams, Wood, & Parke, 2012b). However, the deterrent effect of these laws is likely very modest, as very few jurisdictions have active enforcement.16 Another approach is to legally prohibit financial institutions from processing payments to online (usually foreign) gambling sites. This approach is currently used in Belgium, Estonia, France, Hungary, Israel, Malaysia, Netherlands, Norway, and the U.S.

Here again, the deterrent effect is likely quite modest, considering that there are many foreign financial intermediaries that provide a means to circumvent these rules (some of which have been created to meet this need) (Wood & Williams, 2009). A final approach is to legally constrain what citizens have access to via their Internet Service Provider (ISP). In 2006 Italy became the first country to require all Italian ISPs to block local access to a “blacklist” of foreign online gambling sites. Several other Western countries have since enacted similar legislation: 15

In addition, many (predominantly Islamic) countries ban online gambling by virtue of their ban on all forms of gambling: Afghanistan, Algeria, Bangladesh, Bhutan, Indonesia, Iran, Jordan, Libya, Mali, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syria, United Arab Emirates, and Yemen (Online Casino Suite, 2012). 16

Nonetheless, the prevalence of Internet gambling in each country roughly parallels its legal availability/sanctioning (Wood & Williams, 2009).

37

Belgium, Denmark, Estonia, France, Germany, Israel, Italy, and Slovenia. Although it is not especially difficult for technologically sophisticated people to circumvent ISP blocking, this approach may have a somewhat greater deterrent effect than financial blocking or laws prohibiting consumer participation (Williams, Wood, & Parke, 2012b).

Restricting the Number of Gambling Formats Statistically, the variable that often has the strongest association with problem gambling is not the preferred form of gambling, or proximity to gambling, but rather, the number of games in which a person engages (e.g., Williams, Volberg, & Stevens, 2012; Wood & Williams, 2012). This may be because gambling versatility is a characteristic feature of problem gambling. This is similar to the observation that although problem drinkers may have a preferred drink, many types of alcohol are usually consumed. Even if versatility is characteristic of problem gamblers, it does not preclude limiting the number of gambling formats available so as to reduce the harm (i.e., in the same way that limiting money or time spent gambling would be helpful). Unfortunately, there is no research or cross-jurisdictional comparisons of this issue. Although there are many jurisdictions that limit certain forms of gambling there are no jurisdictions that have a maximum number of permissible formats.

Restricting Gambling to Dedicated Gambling Venues “Convenience gambling”, whereby gambling is available outside dedicated venues, is sometimes cited as an important contributing factor for problem gambling. Worldwide, it is typical for bingo, horse racing, and casino table games to occur in dedicated venues. Separate sports betting shops are also common in Europe and Australia. In contrast, it is a common practice for the purchase of lottery tickets and instant win tickets to occur in a range of retail outlets. The main source of variation (and scientific focus) concerns the placement of EGMs, which are restricted to dedicated gambling venues in some countries but occur in a wide variety of venues in other jurisdictions. Many European countries permit EGMs outside of dedicated gambling venues. EGMs can be found in:  bars (Belgium, Denmark, Finland, Germany, Hungary, Iceland, Italy, Netherlands, Norway, Spain, U.K.)  arcades and clubs (Belgium, Denmark, Finland, Germany, Hungary, Lithuania, Netherlands, Slovenia, U.K.)  restaurants (Denmark, Finland, Germany, Hungary, Iceland, Netherlands, Norway, Spain)  hotels (Germany)  and various types of retail outlets (e.g., gas stations, supermarkets, video rental stores) (Finland, Iceland).

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Prior to 2000 the Netherlands also had EGMs in bowling alleys, sport canteens, and snack bars. Prior to 2007 Norway had EGMs in shopping centres, grocery stores, and cafes. Prior to 2005 Switzerland had EGMs in amusement arcades, restaurants and bars. Prior to 2009 Poland had EGMs in restaurants, bars, clubs, shops and service stations. The European countries that currently prohibit EGMs outside of dedicated gambling establishments are Estonia, France, Greece, Luxembourg, Poland, Portugal, and Switzerland. In addition, they are banned from ‘low barrier’ locations (e.g., bars; lounges; clubs) in Lithuania, Latvia, and the Netherlands (European Commission, 2006). In Australia, all states and territories permit EGMs outside casinos with the exception of Western Australia. In Canada, 2 out of 10 provinces do not permit EGMs outside of gambling venues: Ontario and British Columbia.17 In contrast, in the United States, only 6 states allow EGMs outside of gambling venues: Louisiana, Montana, Nevada, Oregon, South Dakota and West Virginia. The unique impact of limiting gambling opportunities to dedicated venues is difficult to determine, as jurisdictions with the policy also tend to have other restrictive policies as well (e.g., Western Australia).

A more common problem is that jurisdictions with the policy often compensate by having many more ‘dedicated gambling venues’ so that the actual physical availability/proximity of EGM gambling is not significantly different. For example, France had 197 in 2012, more than any other European country. Similarly, Estonia, with a population of only 1.3 million had 168 casinos in 2009 (Laansoo & Niit, 2009). Greece has recently announced an intent to create 819 ‘mini-casinos’ (Yogonet.com, 2011). In the United States, the largest number of casinos tends to be found in states that do not permit EGMs outside of dedicated gambling venues. For example, California has 162 dedicated venues, Oklahoma has 109, and Washington has 149) (American Gaming Association, 2012). In Canada, Ontario and British Columbia have historically permitted more casinos/racinos than any other province.18 This circumstance likely explains why residents of these two provinces patronize EGMs within casinos/racinos at a higher rate than any other province. In Ontario, 27% of adults had gambled on venue-based EGMs in Ontario (Williams & Volberg, in preparation) and 22% in British Columbia in 2007 (Canadian Partnership for Responsible Gambling, 2008).

As seen in Table 1, the overall relationship is relatively weak between provincial problem gambling prevalence rates in Canada for 2002 (CPGI 5+), and the number of EGMs outside of gambling venues per capita (r = .37, ns), and nonexistent between problem gambling prevalence rates and the number of EGM locations per capita (r = .01, ns) (this is true even when removing Ontario and British Columbia from the correlations). In the United States, there 17

However, Native reserves in Nova Scotia often have VLTs in gas stations, laundromats, and convenience stores.

18

In recent years Alberta has had a similar number of casinos/racinos to British Columbia and Ontario.

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is no significant difference in the average standardized rates of problem gambling in states that have historically had EGMs outside casinos (Louisiana, Montana, Nevada, Oregon, South Dakota; prevalence = 2.3%) compared to states without EGMs outside casinos (n = 23, prevalence = 2.2%), t (26) = .22, p = .83) (data taken from Williams, Volberg, & Stevens, 2012).

Table 5. Correlates of Canadian Provincial Problem Gambling Prevalence in 2002.

Problem Gambling Prevalence EGMs outside of casinos/racinos per 100000 adults # locations EGMs occur outside casinos/racinos per 100000 adults

Correlation with PG Prevalence

QU

PEI

ONT

NF

NB

BC

NS

AB

SK

MB

1.0

0.9

1.2

1.3

1.4

1.4

1.6

1.7

2.3

2.4

237

388

0

633

433

0

441

255

507

582

r = .37 tau-b = .30

62

87

0

138

111

0

73

50

93

67

r = .01 tau-b = -.07

Provinces are Alberta (AB), Manitoba (MB), New Brunswick (NB), Newfoundland & Labrador (NF), Nova Scotia (NS), Ontario (ONT), Prince Edward Island (PEI), Quebec (QU), and Saskatchewan (SK).

These results are somewhat surprising considering the fact that increasing the number of alcohol outlets per capita tends to increase alcohol consumption (Babor, Caetano, Casswell, et al., 2010; Stockwell et al., 2009; Wagenaar & Holder, 1995; Wagenaar & Langley, 1994). However, what the present results perhaps indicate is that each available EGM represents an independent ‘outlet’ as opposed to each place where EGMs are located. Thus, total EGMs per capita may continue to be a much better predictor of jurisdictional problem gambling prevalence rates. A corollary of this point is that concentrating gambling opportunities within gambling venues may simply result in corresponding local concentrations of problem gambling (e.g., Shaffer et al., 2004).

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Restricting the Location of Gambling Venues Historically, casinos in Europe and the United States were placed in tourist destinations away from major urban centres. This is still largely the case in Asia and Africa. The historical rationale was that a) the economic benefits of casinos are strongest when they draw new money and wealth into the community rather than simply redirecting local money (Williams, Rehm, & Stevens, 2011), b) casinos would be deleterious for urban, working-class populations, and c) social problems created by gambling go home with the tourist, rather than impacting local social service and health care system (Grinols, 2004; Williams, Rehm, & Stevens, 2011). Although it is true that this strategy partly just shifts the harm to out-of-jurisdiction residents, the actual impact on tourists would be offset by the fact that 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 be less susceptible to gambling addiction. An additional consideration in the placement of gambling venues is that some groups of urban residents are much more susceptible to problem gambling than others. For example, poorer neighbourhoods and lower incomes are positively associated with problem gambling (Welte et al., 2004; 2007; Williams, Volberg, & Stevens, 2012).

In addition, Rush, Veldhuizen, & Adlaf (2007) found that substance abuse and demographic factors were the strongest regional predictors of problem gambling status in Ontario (stronger than gambling venue proximity). In Canada, the national prevalence study of gambling in 2002 (Canadian Community Health Survey (CCHS) 1.2), additionally found that people with less education, and those of Aboriginal descent have significantly higher risk of problem gambling (Marshall & Wynne, 2003). As seen in Figure 2, problem gambling prevalence rates in the Canadian provinces are in fact best predicted by proportion of the population with Aboriginal ancestry (r = .94, p < .01). Almost equally strong is the relationship between provincial rates of alcohol dependence (established in the same CCHS 1.2 survey) and problem gambling prevalence (r = .71, p < .05).

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Figure 2. Aboriginal Ancestry as it Relates to Canadian Provincial Problem Gambling Prevalence in 2002. 3

MB

Problem Gambling Prevalence

2.5

SK 2

NS

BC

AB

1.5

NB

ONT

NF & L

QU

1

r = .94, p < .001 tau-b = .81, p = .001

PEI 0.5

0 0

2

4

6

8

10

12

14

16

Aboriginals as % of Provincial Population Problem gambling prevalence is established by a Canadian Problem Gambling Index (CPGI) score of 5 or higher (Williams & Volberg, 2010). The CPGI was administered as part of the Canadian Community Health Survey (1.2) (May – Sept 2002; n = 34,770). Provinces are Alberta (AB), Manitoba (MB), New Brunswick (NB), Newfoundland & Labrador (NF), Nova Scotia (NS), Ontario (ONT), Prince Edward Island (PEI), Quebec (QU), and Saskatchewan (SK). Aboriginal population figures from the Statistics Canada 2001 Census.

Limiting Gambling Venue Hours of Operation Policies to limit the number of hours that patrons may gamble in any 24 hour period are intended to reduce harm associated with extended play. There is wide variation in this policy with some jurisdictions requiring gambling venues to be closed during certain hours and other jurisdictions allowing 24 hour operation. In Australia, all states and territories except Western Australia currently require a 4 – 6 hour break every 24 hour period (Australian Department of Families, Housing, Community Services and Indigenous Affairs (DFHCSIA) 2012). Prior to 2000 most Australian states had no requirement for shutdown.

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Information is very limited regarding the effectiveness of hours-of-operation restrictions. McMillen & Pitt (2005) found that a mandatory 3 hour shutdown of EGMs in the Australian Capital Territory between 4:00am to 7:00am (implemented in September 2001) had a selfreported beneficial effect on a small number of problem gamblers, and a 3 – 10% impact on club revenue. In contrast, a 3 hour shutdown of EGMs in New South Wales (NSW) in 2002 was deemed to be an ineffective harm minimization strategy (ACNielsen & ACGR, 2003). However, this may have been partly due to the fact that some of the NSW clubs varied the time of their shutdown hours, and that the Sydney Star City casino was exempt from the shutdown (McMillen & Pitt, 2005). The province of Nova Scotia shut-down of EGMs in locations outside of casinos at midnight, which resulted in a self-reported 18% reduction in spending among a random sample of problem gamblers, and a decrease in overall revenue of between 5.1 - 8.7% (Nova Scotia Gaming Corporation, 2005). Reduced hours of operation continue to make theoretical sense considering a) the general premise that reduced availability leads to reduced problems, and b) evidence in the alcohol field that restricted hours and days of operation reduce social harm (Babor, Caetano, Casswell, et al., 2010; Chikritzhs & Stockwell, 2006; Stockwell & Chikritzhs, 2009).

However, as with reductions in the number of EGMs, unless availability reductions are meaningful and substantial, it seems unlikely that a significant overall beneficial impact will be attained.

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RESTRICTIONS ON WHO CAN GAMBLE Prohibition of Youth Gambling Worldwide, it is a common policy to restrict gambling to individuals who are of legal adult age (Rose, 2001), which ranges from 15 – 21, depending on the country (18 being most common)19. There are some important regional variations on this policy. For example, there is currently no age restriction for purchasing lottery and instant win tickets in Poland (Dzik, 2009). There are no age restrictions for non-casino gambling in Slovenia (Macur, Makarovic, & Roncevic, 2009). There are no age limits to play electronic gambling machines (‘fruit machines’) with low prize limits in the United Kingdom. Prior to 2004, slot machines outside casinos in Finland could be played by any child or adolescent if accompanied by an adult (current age required is 16, raised to 18 in July 2011) (Jaakkola, 2009). Sixteen year olds can purchase lottery tickets in England and Finland (raised to 18 in October 2010). Historically, in Estonia, there was no age limit on purchasing lottery tickets (16 was made the minimum age in 2010) (Laansoo & Niit, 2009). Prior to 2007 lottery tickets could be purchased by youth in Israel (Gavriel-Fried & Derevensky, 2009). A few U.S. states (and Alberta, Canada) permit bingo playing at age 16. Citizens of Malta have to be 25 to enter a Maltese casino.

Some countries lack specific laws prohibiting youth gambling and, where laws exist, there is also wide variation regarding enforcement. In general, enforcement tends to be more rigorous where gambling occurs in adult-only venues (e.g., casinos, bars/clubs/lounges) and less so where gambling is available in public locations. Consequently, North American and Australian youth tend to have low rates of casino table game and gambling machine play as they are only available in adult venues, but high rates of lottery and scratch ticket play which is available in public locations (Delfabbro, Lahn, & Grabosky, 2005; Felsher, Derevensky, & Gupta, 2004; Jacobs, 2004). In contrast, gambling machine play is among the most common gambling activity among youth in Nordic countries, as these machines have historically been located in public locations (Johansson & Gotestam, 2003; Olason, Sigurdardottir, & Smari, 2006). Between jurisdiction comparisons of gambling and problem gambling in youth and definitive prevalence rates are difficult to establish because of the range of instruments (i.e., SOGS, SOGSRA, DSM-IV, DSM-IV-MR-J), as well as serious concerns about whether these instruments overestimate true prevalence rates (e.g., Ladouceur, Bouchard, Rheaume, et al., 2000; Pelletier, Ladouceur, Fortin, & Ferland, 2004; Tremblay et al., 2010).

Nonetheless, some interesting observations can be made about obtained rates. First, despite prohibition, the past year prevalence of youth problem gambling, which ranges from 2% to 6%, appears to be at least as high, if not higher than adult rates (Rossen, 2001; Shaffer & Hall, 2001, Williams, Volberg, & Stevens, 2012). Second, no obvious differences in youth prevalence rates appear to exist between jurisdictions, despite significant variations in availability and enforcement (Rossen, 19

Wikipedia (2012). Age of Majority.

44

2001; Shaffer & Hall, 2001). Finally, and somewhat surprisingly, countries where youth have greater access to gambling (e.g., the U.K. and Nordic countries) tend to have somewhat lower rates of adult problem gambling (Williams, Volberg, & Stevens, 2012). Hence, it is also worth considering whether early exposure to gambling could have beneficial effects on the level or intensity of subsequent adult gambling. The analogy here is the oft cited lower rate of adult alcoholism in many countries where children are exposed to alcohol at an early age (e.g., China, Israel, southern European countries such as Italy) (Heath, 1995; Pittman & White, 1991). However, it is important to recognize that in many cases early exposure is known to be quite harmful. For example, indigenous groups (e.g., North American Aboriginals, Australian Aborigines) and certain countries such as France have very high rates of alcohol dependence despite early exposure.

Furthermore, an early onset of substance use (e.g., Taioli & Wynder, 1991; Dawson et al., 2008) and gambling (Gupta & Derevensky, 1998; Kessler et al., 2008) tends to be a strong correlate of problems later in life.20 Finally, animal research (with much better experimental controls on the relevant variables) has found that adolescent exposure to drugs (e.g., nicotine, alcohol) creates permanent neurochemical changes that results in increased adult consumption of these products with this effect much more pronounced for strains of addiction-prone animals (Diaz-Granados & Graham, 2007; Levin et al., 2003; Rodd-Henricks et al., 2002; Schramm-Sapyta et al, 2008; cf. Slawecki & Betancourt, 2001). What is common among cultures with low rates of alcoholism despite early exposure is ongoing promotion and modelling of moderate use in the context of family, meals, and/or religious service, as well as cultural taboos against drunkenness (Heath, 1995; Pittman & White, 1991). Thus, it is likely that extended modelling during initial use of the product is the important ingredient. This mechanism is also thought to account for the reduced rate of traffic accidents in jurisdictions that have introduced graduated driver licensing (e.g., McKnight & Peck, 2003). Hence, the evidence would suggest that deliberately exposing youth to gambling at a young age is probably counterproductive.

However, modelling responsible gambling to youth prior to their unrestricted ability to gamble on their own would likely have value, as would a graduated ability to gamble independently. A mandatory educational session(s) for all first time gamblers might also have utility. Increasing the Legal Age for Gambling It is also worth considering the utility of raising the legal age for gambling. Currently, the legal age varies from 16 – 25 depending on the type of gambling and the specific jurisdiction. There is very little empirical evidence that establishes the potential effectiveness of applying this approach to gambling. Norway raised its legal age to 18 from 16 and found a coincident decrease in slot machine use (Gotestam & Johansson, 2009). However, considerable evidence of the effectiveness of similar policy measures exists in the alcohol field. For example, lowering the age limit for alcohol consumption (as occurred in the 1970s in North America) resulted in a 20

This observation has resulted in the development of preventive programs that endeavour to delay the onset of experimentation.

45

significant increase in alcohol-related harm (Babor, Caetano, Casswell, et al., 2010). Similarly, a comprehensive review of all studies published on the legal drinking age between 1960 and 2000 concluded that increasing the legal age for purchase and consumption of alcohol from 18 to 21 was more effective than any other policy for reducing alcohol-related harm (e.g., fatal alcohol related motor-vehicle accidents, heavy alcohol consumption) among students and young adults (Wagenaar & Toomey, 2002) (see also Keller, Frye, Bauerle, & Turner (2009) and Fell et al. (2008)). Moreover, the jurisdiction-specific magnitude of the impact was found to be directly related to the degree to which the change in the legal drinking age was legally enforced (Babor, Caetano, Casswell, et al., 2010).

Restricting Venue Entry to Non-Residents Some countries do not permit local residents to gamble at casinos. Historically, this was not uncommon in European countries (e.g., France; Slovenia till 1990; Germany from 1938 – 199521, Meyer, Hayer, & Griffiths, 2009). Current examples include the Bahamas, Malaysia, Papua New Guinea, Vietnam, and Nepal. Australia does not permit residents to gamble at any Australianbased online casino although it did permit its citizens to wager money with Australian online sports and race books, poker rooms, lottery sites, and skill game sites. In other countries, resident access is severely restricted. Currently, in Slovenia, HIT Casinos only permit residents from the local region to gamble at their venues 4 times a month (Macur et al., 2009). South Korean citizens are only allowed to gamble at one of South Korea’s 16 casinos. The rationale for this policy is the same as the rationale for locating casinos in tourist areas: to ensure that casino revenues come from outside the jurisdiction and to protect the local populace from harm. Although theoretically sound, there is a lack of empirical evidence on the effectiveness of this policy in preventing problem gambling amongst the citizenry. It is clear that gambling remains commonplace in some countries where this policy exists.

Nonetheless, casino gambling is uncommon in South Korea, with only 1.5% of the adult population engaging in this in 2011 (Williams, Lee, & Back, in press), and rates of problem gambling (0.8%) are significantly lower than other Asian jurisdictions (Singapore, Hong Kong, Macau) (Williams, Volberg & Stevens, 2012). Another important observation is that despite the restrictions on legal gambling availability, only 0.1% of South Koreans report illegally gambling at a domestic casino, only 0.6% report gambling at foreign casinos, and only 0.7% report online gambling at an offshore site (Williams, Lee, & Back, in press).

21

Local residents in this case meant people from the particular city where the casino was located.

46

Restricting Venue Entry to Higher Socioeconomic Classes Dress codes requiring formal attire exist in some European countries (e.g., France, Germany, Holland), partly to maintain the sophisticated ambience, and partly to cater to higher socioeconomic classes. Significant entry fees are required in some countries (e.g., Papua New Guinea), which are intended to have the same effect. In Singapore, the 2010 Casino Control Act bans casino entry to anyone who has claimed bankruptcy or receives social assistance and residents are required to pay a $100 admission fee or $2,000 for an annual pass. The German state of North Rhine-Westphalia recently banned the unemployed from betting on sporting events (RTE News, 2011). Low socioeconomic status is a strong predictor of problem gambling status in most countries (Williams, Volberg, & Stevens, 2012). (Surprisingly, Singapore is one of the few countries where middle and high income has a stronger association with problem gambling (Singapore Ministry of Community Development, Youth and Sports, 2005, 2008)). Hence, this policy and associated measures to limit or otherwise contain gambling expenditures among lower economic groups may have some utility in preventing the harm associated with problem gambling.

Casino Self-Exclusion 22 Informal casino self-exclusion programs have been used by various casinos around the world since at least the 1960s. The first formal casino self-exclusion program was initiated in 1989 in Manitoba, Canada, coincident with the opening of the country’s first permanent, year-round casino (Nowatzki & Williams, 2002). In the Netherlands, Holland Casino developed a program in 1990. In the United States, a tribal casino in Connecticut implemented a self-exclusion program in 1994, and Missouri developed the first state-wide program in 1996. Since that time, many casinos and jurisdictions around the world have adopted self-exclusion programs (Nowatzki & Williams, 2002; Responsible Gambling Council, 2008). In Europe this includes Austria, Belgium, Bulgaria, France, Malta, the Netherlands, Portugal, Slovenia, and the United Kingdom). In addition, several Internet gambling sites also offer self-exclusion programs (Griffiths, 2012; Wood & Williams, 2007a; 2009). The effectiveness of self-exclusion programs can be measured in three ways. The first is the utilization rate for the program. On the basis of self-exclusion data for 7 Canadian provinces with casinos (as provided by regulatory agency staff to one of the authors (BW) in 2005), between 0.6% and 7.0% of problem gamblers signed up to self-exclude, depending on the province.