1. What Do Gaming Regulators Regulate? A Public Health Perspective on Disordered Gambling & Regulation Richard LaBrie, Ed.D.. North American Gaming Regulators Association 2006 Conference Scottsdale, Arizona

2. Source of Demands for Regulation The perception that gambling is a problem and an increasing problem? The perception that gambling is a problem and an increasing problem? The perception of gamblers as unable to regulate themselves—as if they have an addiction? The perception of gamblers as unable to regulate themselves—as if they have an addiction? The perception of the gaming industry as unable to regulate itself? The perception of the gaming industry as unable to regulate itself?

3. Selected Models Moral turpitude Moral turpitude Psychological Psychological Bad Judgment Bad Judgment Behavioral Behavioral Cognitive Cognitive Cognitive-Behavioral Cognitive-Behavioral Adaptation Adaptation Social Social Economic Economic Exposure Exposure Psycho-Social Psycho-economic Impulse Control Disorder Regulatory problems Biological Reward deficiency Neuro-genetic vulnerability Public Health Multidimensional issue

4. On a Public Health Perspective “The enduring value of a public health perspective is that it applies different 'lenses' for understanding gambling behaviour, analysing its benefits and costs, as well as identifying strategies for action” (p. 286). “The enduring value of a public health perspective is that it applies different 'lenses' for understanding gambling behaviour, analysing its benefits and costs, as well as identifying strategies for action” (p. 286). Harvey A. Skinner Harvey A. Skinner (1999). Gambling: achieving the right balance. Journal of Gambling Studies, 15(4), 285-287. (1999). Gambling: achieving the right balance. Journal of Gambling Studies, 15(4), 285-287.

5. Protect & improve the health of populations Protect & improve the health of populations Identify proximal & distal determinants of disease Identify proximal & distal determinants of disease biological & behavioral mechanisms responsible for disease biological & behavioral mechanisms responsible for disease social situations that place people at higher risk for developing disease social situations that place people at higher risk for developing disease Poverty, exposure to toxic substances, access to gambling, opportunities for health care Poverty, exposure to toxic substances, access to gambling, opportunities for health care Primary Elements of a Public Health Perspective

6. A Public Health View of Communicable Disease Environment Host Agent Vector

7. A Public Health View of Disordered Gambling Environment Gambler Game Money

8. 1. Scientific research is the foundation of public health knowledge 2. Public health knowledge derives from population-based observations 3. Public health initiatives are proactive 4. Public health perspectives are balanced The Four Principles of Public Health Perspectives

9. Science Provides the Foundation for Public Health Programs Researchers at Harvard study the effects of casino gambling on laboratory rats.

10. Epidemic Schematic

11. Number of Enrolled Self-Excluders* * Shaffer, H. J., LaBrie, R. A., LaPlante, D. A., & Nelson, S. B. (2004). Disordered Gambling in Missouri: Regional Differences in the Need for Treatment. Available at www.divisiononaddictions.orgDisordered Gambling in Missouri: Regional Differences in the Need for Treatment

12. Courses of Exposure and Adaptation

13. Regulatory Consequences of Exposure & Adaptation Models Exposure Exposure Leads to slow response, or under-reaction given the “incubation” of disease following exposure Leads to slow response, or under-reaction given the “incubation” of disease following exposure Adaptation Adaptation Leads to regulatory over-reaction since the population tends to adjust for the presence of the toxic agent Leads to regulatory over-reaction since the population tends to adjust for the presence of the toxic agent

14. Tertiary Prevention Secondary Prevention Primary Prevention Shaffer, H., LaPlante, D., LaBrie, R., Kidman, R., Donato, A., Stanton, M. (2004) Toward a Syndrome Model of Addiction: Multiple Expressions, Common Etiology. Harvard Review of Psychiatry, 12, 367-374.Toward a Syndrome Model of Addiction: Multiple Expressions, Common Etiology

16. Non Gambling Range of Behaviors Framework for Public Health Action Range of Interventions Primary preventionSecondary preventionTertiary prevention Health PromotionHarm Reduction intensiveTreatmentbrief Range of Gambling Problems none mild moderate severe Healthy Gambling Unhealthy

17. Public Health Regulatory Targets People & Groups People & Groups Population of gamblers Population of gamblers Gaming industry Gaming industry Gambling activities Gambling activities Exposure & access to gambling Exposure & access to gambling Gambling settings Gambling settings Industry growth Industry growth Activities within gambling setting Activities within gambling setting Activities around gambling setting Activities around gambling setting Activities or “games” Expectations about the population attributes or “set” “Setting” context

18. Primary Products of Regulatory Efforts Hotlines & help lines Hotlines & help lines Advertising Advertising Alcohol service Alcohol service Credit Credit Employee training Employee training Loss limits Marketing & direct mail Signage Public awareness Self-exclusion Treatment funding Source: American Gaming Association (March 2002). Statutes and regulations in commercial casino states concerning responsible gaming.

19. Classifying the Objects of Regulatory Activities Initiation Initiation Awareness Awareness Prevention Prevention Advertising/Marketing Advertising/Marketing Gambling & gambling-related activities Gambling & gambling-related activities Signage Signage Employee training – pathological gambling & education Employee training – pathological gambling & education Alcohol service Alcohol service Credit restrictions Credit restrictions Loss limits Loss limits Consequences of Gambling Consequences of Gambling Self-exclusion Self-exclusion Helpline Helpline Treatment Treatment

20. Regulatory Activities 2002 Source: American Gaming Association. (2002). Statutes & Regulations in Commercial Casino States Concerning Responsible Gaming.

21. Regulatory Activities 2002 Source: American Gaming Association. (2002). Statutes & Regulations in Commercial Casino States Concerning Responsible Gaming.

22. Targets of Regulatory Activities 2002 Source: American Gaming Association. (2002). Statutes & Regulations in Commercial Casino States Concerning Responsible Gaming.

23. Natural History of Gambling: Targets of Statutes & Regulations in Casino States (2002) Source: American Gaming Association. (2002). Statutes & Regulations in Commercial Casino States Concerning Responsible Gaming.

25. Public Health Strategies Prevent gambling related problems Prevent gambling related problems Promote healthy attitudes, behaviors & policies toward gambling Promote healthy attitudes, behaviors & policies toward gambling Protect vulnerable groups Protect vulnerable groups

26. Public Health Principles Make community level prevention a priority Make community level prevention a priority Promote mental health & build community capacity for mental health Promote mental health & build community capacity for mental health Cognitive Cognitive Emotional Emotional Foster personal and social responsibility Foster personal and social responsibility Policies Policies Practices Practices Incorporate harm reduction strategies Incorporate harm reduction strategies

27. Harm Reduction Strategies Healthy gambling guidelines for the public Healthy gambling guidelines for the public Develop vehicles for early identification Develop vehicles for early identification Screens, education, community resources Screens, education, community resources Develop moderation and abstinence goals that can be offered non-judgmentally Develop moderation and abstinence goals that can be offered non-judgmentally

28. Special Thanks Dr. Howard Shaffer Dr. Howard Shaffer Dr. Richard LaBrie Dr. Richard LaBrie Dr. Sarah Nelson Dr. Sarah Nelson Rachel Kidman Rachel Kidman Tony Donato Tony Donato Michael Stanton Michael Stanton Allyson Peller Allyson Peller Dr. Mark Albanese Dr. Mark Albanese Bree Tse Bree Tse Siri Odegaard Siri Odegaard Sarbani Hazra Sarbani Hazra Gabriel Caro Gabriel Caro Melissa Marcarelli Melissa Marcarelli Chrissy Thurmond Chrissy Thurmond Christine Reilly Christine Reilly Iowa Department of Public Health Nevada Department of Public Health Massachusetts Department of Public Health National Center for Responsible Gaming Missouri Port Authority National Institute on Alcohol Abuse and Alcoholism ValueOptions betandwin.com Massachusetts Driving Under the Influence of Liquor Treatment Program Massachusetts Council on Compulsive Gambling Wisconsin Association on Alcohol and Other Drug Abuse

29. For more information… www.divisiononaddictions.org www.divisiononaddictions.org www.divisiononaddictions.org Division on Addictions’ website Division on Addictions’ website Publications, presentations, and current project descriptions available Publications, presentations, and current project descriptions available www.basisonline.org www.basisonline.org www.basisonline.org Brief science reviews and editorials on current issues in the field of addictions Brief science reviews and editorials on current issues in the field of addictions Addiction resources available, including self-help tools Addiction resources available, including self-help tools rlabrie@hms.harvard.edu rlabrie@hms.harvard.edu