Horses and Carriages Max Abbott Professor of Psychology and Public Health Pro Vice-Chancellor (North Shore) and Dean, Faculty of Health and Environmental Sciences Director, Gambling Research Centre Auckland University of Technology New Zealand Gaming Expo Conference 15 and 16 February 2006

“Love and marriage, love and marriage, they go together like a horse and carriage. This I’ll tell you, brother - you can’t have one, without the other.” (Childhood memory, recently recovered)

This paper considers the following question: “What is the nature of the relationship between electronic gaming machines (EGMs) and problem gambling?”  Important in light of current legislative, regulatory and other measures to cap, expand or reduce EGM numbers and accessibility  Relevant to measures to prevent or reduce gambling-related harms

Exposure (availability) hypothesis  Widely believed increased gambling availability leads to rise in prevalence of excessive gambling and related harms (Productivity Commission, 1999; USA National Research Council, 1999; UK Gambling Review Body, 2001)  EGMs considered particularly ‘addictive’ – “crack cocaine of gambling”  Focus of international debate currently

Addiction 2006, Vol. 100, pp Orford and Abbott, Blaszczynski, Ronnberg, Room and Shaffer commentaries Room: “Complex and multifactorial though causation is, the more the product is supplied in an accessible form, the greater the volume of consumption and the greater the incidence and prevalence of harm.” “I doubt there would be many who would argue with that basic public health law when it comes to the supply of alcohol, tobacco and other drugs of various kinds. It would be very surprising indeed if that general rule was not also true for gambling, and the onus should be upon those who think gambling might be an exception to the general law to prove their case.”

Abbott (2005): “Most things that go up usually come down. This is also true in epidemiology. Abbott et al (2004b) cite research strongly suggesting that problem gambling prevalence will eventually level out and decline, even if accessibility continues to increase.” Shaffer (2005): “Observations about gambling-related problems in Nevada provide support for the adaptation hypothesis of addiction. That is, after the novelty of initial exposure, people gradually adapt to the risks and hazards associated with potential objects of addiction.”

Previous statement: “…as people and society more generally obtain increased experience with new forms of gambling, adaptations will be made that enable problems to be more readily countered or contained. Increased public awareness of problem gambling and its early warning signs, the development of informal social controls and the expansion of treatment and self-help options, may play a part in this process. Under this more optimistic scenario, the proposed relationship between rising gambling participation and increasing problems may be attenuated or possibly reversed.” (Abbott, Williams and Volberg, 1999) Shaffer also made earlier reference to this adaptation hypothesis but considered that it would be slow - “perhaps only after decades and generations of social learning.” (Shaffer, Hall and Vander Bilt, 1997)

Working hypotheses – incorporate both exposure and adaptation models 1.During exposure to new forms of gambling, particularly continuous forms, previously unexposed individuals, population sectors and societies are at high risk for the development of gambling problems 2.Over time, years rather than decades, adaptation (‘host’ immunity and protective environmental changes) typically occurs and problem levels reduce, even in the face of increasing exposure 3.Adaptation can be accelerated by regulatory and public health measures 4.While strongly associated with problem development (albeit comparable to many other continuous forms when exposure is held constant) EGMs typically give rise to more transient problems

Exposure hypothesis - corroborative  Problem gamblers – high levels of EGM participation/expenditure (clinical presentations and general population surveys)  Some studies - higher prevalence in jurisdictions with greater exposure levels (number of EGMs/EGM expenditure per capita)  Prevalence rates and clinical presentations increased in some groups following increased EGM participation (e.g. women in Australia, NZ, parts of North America)  Most studies, high ‘lifetime’ prevalence among teenagers/young adults relative to adults

Adaptation hypothesis - corroborative  State/provincial replication surveys divided between those finding higher and lower prevalence rates at follow-up  1995, 1999 and New Zealand national surveys had lower rates than 1991 national survey (current rates: 1.1%, 0.4%, 0.5%)  Australian state/territory surveys and 1999 national survey (2.1%) substantially lower rates than initial 1991 ‘four cities’ survey (6.6%)

 Nevada – much higher prevalence than other states in first US national survey (late 1970s) – recently lower (e.g. 9x more exposed than people in Iowa but prevalence lower than US national average)  US national survey (Welte et al, 2002) found region with highest gambling expenditure (New England) had lowest prevalence; region with highest prevalence (West) did not have higher expenditure than other regions

 6 recent replication surveys found reduced percentage of frequent gamblers despite increased per capita expenditure – those with reductions in prevalence had more comprehensive problem gambling services  1999 NZ prospective study findings challenge assumption that high youth/young adult prevalence means increasing problems – two reasons (1) most older ‘lifetime’ problem gamblers don’t report having had previous problems when reassessed; (2) most problems remit, especially if linked with EGM participation

 1999 (and 2002/03) NZ national surveys found some previously high-risk groups (unemployed, beneficiaries, youth/young adults) no longer high risk. Australian national survey found little difference across sociodemographic groups Examples (NZ): %0.4%* %0.5% Male 2.0%0.4%* Female 1.0%0.5%

 Australian (and Norwegian/NZ) national survey data (SOGS-R) suggest prevalence initially increases with rising exposure then attenuates Figure 1: Comparing Australia, New Zealand and Norway

 Canadian provincial data (CPGI) somewhat similar although much less variability in EGM densities Figure 2: Comparing the Canadian Provinces

Norway – an interesting case?  Lowest national prevalence rates (adult and youth) and no increase from  At time of most recent prevalence studies, Norway similar machine density to NZ (5/1,000; 6/1,000 adults)  Machines widely accessible – petrol stations, supermarkets, shopping centres; few restrictions/regulations; and rudimentary problem gambling services  Why is prevalence so low and apparently not increasing?

Table 1: Comparing National Problem Gambling Prevalence Rates

Reducing machine numbers – what does it do?  Pulling the plug: South Dakota, 1994 (treatment centres - 68 inquiries per month preceding year; 10 during.3 month shut down; 24 following 3 months)  Less drastic responses: Caps – Victoria 1995 statewide binding cap (ref. previous data set: Productivity Commission) Expenditure approx. 2x per machine higher; prevalence similar to states with many more machines and similar EGM expenditure per capita  2002 regional caps (+smoking ban and operating hours)

Reduced machine numbers in 4 regions – compared expenditure changes with matched regions – no significant reductions or ‘spill-over’ Maximum EGM reduction 15% and number remained above state average Note: 6-9% reduction in expenditure in metropolitan capped and ‘control’ areas (smoking ban and removal of 24-hour venue operation?) Also substantial reductions in gambling helpline calls and counselling cases statewide (5,309 in 2001; 3,508 in 2003)

Public Health Approaches Objective – health promotion and reduced incidence (new cases/‘inflow’) and prevalence (total ‘stock’) 1.Reduce exposure to the agent (gambling) 2.Modify other environmental factors (risk and/or protective) that influence the development of problem gambling 3.Modify host (individual) factors (risk and/or protective) that influence the development of problem gambling Acceleration of ‘outflow’ (natural/self recovery; interventions) can reduce prevalence, but effect generally minimal at population level