A PUBLIC HEALTH PERSPECTIVE ON GAMBLING AND GAMING FACILITIES: A BRIEF LITERATURE REVIEW

OCTOBER 2012

RESEARCH AND EVALUATION DIVISION OF KINGSTON, FRONTENAC AND LENNOX & ADDINGTON PUBLIC HEALTH

Author: Allison Maier, MPH

For more information contact: Dr. Kathleen OConnor, Director, Research and Evaluation Division Kingston, Frontenac and Lennox & Addington Public Health 221 Portsmouth Ave. Kingston, ON K7M 1V5 Tel: (613) 549-1232, Ext 1125 Email: Daphne.Mayer@kflapublichealth.ca

Recommended Citation: Maier, A. A public health perspective on gambling and gaming facilities: a brief literature review. Kingston: Kingston, Frontenac and Lennox & Addington Public Health; 2012.
Kingston 221 Portsmouth Ave., Kingston, ON K7M 1V5 Tel: (613) 549-1232 Or 1-800-267-7875 Fax: (613) 549-7896 Cloyne P.O. Box 59 Cloyne, ON K0H 1K0 Tel: (613) 336-8989 Fax: (613) 336-0522 Napanee 41 Dundas Street, Napanee, ON K7R 1Z5 Tel: (613) 354-3357 Fax: (613) 354-6267 Sharbot Lake P.O. Box 149 Sharbot Lake, ON K0h 2P0 Tel: (613) 279-2151 Fax: (613) 279-3997

Executive Summary
The proliferation of legal gambling opportunities in Canada has been accompanied with increased concern over their impact. Two types of gambling disorders have been defined: problem gambling and pathological gambling. The prevalence of these disorders is debated with estimates in the literature between 2% and 5.5%. There is a higher prevalence in vulnerable groups including youth, Aboriginals and those with low socio-economic status. Numerous studies suggest that the prevalence increases with increased access to gaming facilities, specifically casinos. Gambling disorders can affect an individuals well-being and the well-being of families. The evidence supporting a relationship between gambling disorders and substance abuse and mental illness is strong. Evidence also supports an association between gambling disorders and poor self-reported health and quality of life, and suicide and suicide attempts. Persons with gambling disorders are likely to have personal financial difficulties and can resort to criminal behaviours to address these difficulties. Research shows multiple ways gambling disorders can result in family dysfunction including marital conflict and abuse, and child neglect and abuse. A health perspective on the broad impacts of gambling on society has been adopted by various health organizations. This perspective includes considering the possible positive economic and social changes brought to a community by the addition of a casino. However, the research to date is inconclusive over the net effect. There is weak evidence suggesting an association between recreational gambling and better physical health, but there is also evidence that gambling disorders have broad societal costs. Based on the current state of knowledge on the effects of casinos, health organizations across Canada have adopted a harm reduction strategy.

A public health perspective on gambling and gaming facilities: a brief literature review

Table of Contents
Executive Summary.................................................................................................................................... i Introduction .............................................................................................................................................. 1 Public Health Perspective .......................................................................... Error! Bookmark not defined. Prevalence of Gambling Disorders............................................................................................................ 1 Public Health Impacts of Gambling ........................................................................................................... 2 Negative health impacts ....................................................................................................................... 2 Positive health impacts ......................................................................................................................... 3 The Availability of Gaming Facilities ......................................................................................................... 3 Conclusion ................................................................................................................................................. 4 References ................................................................................................................................................ 5

A public health perspective on gambling and gaming facilities: a brief literature review

ii

Introduction
Legal gambling opportunities in general and casinos in particular have become increasingly available in Canada, the United States and the rest of the world. Based on continuing research, the Canadian Public Health Association (CPHA) has adopted a Public Health Perspective on gambling which embodies public health values that reflect concern for the impact of gambling expansion on vulnerable, marginalized and at-risk population groups 1(p2) and considers the benefits and harms to individuals and communities arising from gambling activities2(p1208) The purpose of this literature review is to provide a summary of the current state of knowledge on the health impacts of gambling with a focus on gaming facilities such as casinos.

Prevalence of Gambling Disorders

Gambling, also known as gaming, is defined as risking money or something of value on the outcome of an event involving chance when the probability of winning or losing is less than certain.1(p1) Numerous gaming types exist, both legal and illegal; for example: casinos, slots and electronic video lottery terminals (VLTs), bingo, instant scratch lottery tickets, and sports betting.1 Gambling opportunities also exist on the Internet.1 Two definitions have been adopted to identify gambling disorders. Problem gambling refers to a progressive disorder characterized by: a) continuous or periodic loss of control over gambling; b) preoccupation with gambling and money with which to gamble; c) irrational thinking; d) continuation of the activity despite adverse consequences.1(p1) Pathological gambling is defined by the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders as an impulse-control disorder.5 It is characterized by persistent and recurrent maladaptive gambling behaviour that disrupts personal, family or vocational pursuit, and key symptoms include preoccupation with gambling, needing to gamble with increasing amounts in order to achieve the desired excitement, and withdrawal symptoms when attempting to control or cut-back on gambling.5(p671) Numerous gambling disorder prevalence estimates exist. Using data from the Canadian Community Heath Survey (CCHS), it has been estimated that 2% of Canadians 15 years and older have gambling problems.1 The literature regularly cites that over a lifespan 1.2% of American adults will be pathological gamblers and an additional 1.5% will be problem gamblers.6 A Harvard University meta-analysis of North American prevalence studies estimated that the lifetime prevalence for these two disorder combined was 5.5%.1 A recent study by the Canadian Partnership for Responsible Gambling found that 76% to 79% of adult Canadians participated in some form of gambling.7 Furthermore, in Ontario, 16-26% of adults used casino slots and 6-6.5% participated in casino table games.7 The prevalence of problem gamblers in Ontario was found to be between 0.4 0.8% and moderate risk gamblers between 2.0 3.4%.7 Gambling prevalence has been found to be higher among vulnerable groups such as Aboriginals,1 youth,8 and those with low socio-economic status.9-11 Huang and Boyer found that youth, especially young men, were at a higher risk; specifically, they observed a polarized pattern of youth gambling, because they seem either to abstain from gambling or to engage in more problematic gambling.8(p663) Lower income households have been found to spend disproportionately more of their income on gambling,11 and a study by Welte et al found that for every increase of standard deviation in neighbourhood A public health perspective on gambling and gaming facilities: a brief literature review 1

disadvantage, the odds of being a pathological or problem gambler increased by 69%.9(p417) A study on seniors in Ontario found that seniors with secondary school education had a 51% lower risk of gambling problems than those without; this trend also existed for higher levels of education.10

Health Impacts of Gambling

Gambling is hypothesized to have both positive and negative health impacts at the individual, intrapersonal and community levels. These impacts range from direct health effects, i.e. gambling may increase stress levels, to indirect, i.e. improvement of health through a stronger community economy. Negative health impacts Problem and pathological gambling have been associated with numerous individual negative health effects. Multiple studies, including one in Ontario, have found that persons with gambling disorders have poorer self-reported health12-14 and report higher rates of stress-related physical ailments, including severe symptoms of heartburn and backache.13;15 Scherrer et al found that after adjusting for confounders including co-occurring substance abuse and psychiatric disorders, pathological gamblers had the lowest health-related quality of life scores, followed by problem gamblers, with non-gamblers having the best scores. There were statistically significant differences in scores between the three groups.16 This trend was also observed in a small study of casino patrons, where self-rated quality of life was lower among pathological gamblers than non-problem gamblers.17 Mental illness and substance abuse rates are typically higher in problem and pathological gamblers than in the general population.1;10;12;18-22 Toneatto et al found gamblers had higher rates of alcohol and other substance use than the rest of the population.19 In a study of pathological gamblers, Petry et al found rates of mood disorder to be 49.6%, anxiety disorder 41.3%, personality disorder 60.8%, alcohol use disorder 73.2%, drug use disorder 38.1% and nicotine dependence 60.4%.20 The difference in rates of mental illness and addiction between problem or pathological gamblers and non-gamblers or both, and recreational gamblers has been found to be statistically significant in multiple studies, including an Ontario study.10;12;20;21 Another Ontario study found adjusted odds ratios of 6.51 for gambling problems and substance abuse and 3.88 for gambling problems and alcohol dependence.10 A systematic review performed in 2010 found a mean prevalence of nicotine dependence of 60.1%, substance use disorder of 57.5%, any type of mood disorder of 37.9% and any type of anxiety disorder of 37.2%.22 The authors noted that a range of values existed in the studies, which suggests there is variation in individual populations, but regardless it is evidence of a high rate of mental illness and substance abuse in problem and pathological gamblers.22 Additionally, Toneatto et al determined that the rate of problem gambling among those with substance issues increases with the introduction of a new casino.19 Most of the research on mental illness and substance abuse in gamblers considers them to be co-morbid conditions, and these disorders are often assumed to pre-date the development of gambling disorders.1;6;20 Cunningham-Williams et al used age-of-onset information to determine that gambling problems occurred after the onset of alcoholism in 65% of cases and after the onset of nicotine dependence in 67% of cases.21 A study by Feigalman et al found that persons with both substance abuse and gambling disorders had higher dysfunctionality (as measured by treatment-seeking behaviours and problems with the law) than individuals with either individual disorder.23 In conclusion, while the issue

A public health perspective on gambling and gaming facilities: a brief literature review

of causality between these disorders is complex, there is evidence that the important health consideration is the high rates of concurrent risky behaviours. Some studies have also reported higher suicide and suicide attempt rates amongst gamblers.1;14;15;24-26 A study of college students in Quebec found that 27% of pathological gamblers had attempted suicide compared to 7% of students with no gambling disorder.15 Using CCHS data, Newman and Thompson found an adjusted odds ratio for problem gambling and suicide attempts of 3.43.24 Canadian women problem gamblers were 3.6 times more likely to have suicidal ideation than non-problem gamblers, and the odds ratio for suicide attempts was 4.7.14 A study in Atlantic City and Las Vegas found elevated rates of suicide compared to non-gambling communities; specifically, it found that the elevated rates in Atlantic City did not appear until after the introduction of casinos.25 The authors concluded that these results supported a hypothesis that one or more of the following subpopulations experience elevated risks of suicide: 1) gamblers visiting gaming communities; 2) spouses of gamblers or children of gamblers who visit gaming settings in the company of a gambling relative (but do not themselves gamble); 3) gamblers residing in gaming communities; 4) non-gambling relatives of gamblers who reside in gaming communities; and 5) non-gambling residents who work in the gaming industry.25(p378) Positive health impacts While there is significant evidence on the negative health impacts to problem gamblers, the health impact of gambling on the overall population is less clear. Some evidence exists to support positive impacts of gambling. Using CCHS data, Humphreys et al found that recreational and casual gamblers were less likely to have diabetes, anxiety disorders, moods disorders, and high blood pressure than their non-gambling counterparts.30 It has been hypothesized that this positive association is due to gambling as a source of socialization, relaxation or hopefulness, though evidence does not exist to support a mechanism for this relationship.1;30

The Availability of Gaming Facilities

There is a growing body of literature supporting the hypothesis that the prevalence of problem and pathological gamblers in the general population increases with access to gambling opportunities.23 Access to gambling opportunities includes: physical proximity to gaming facilities (i.e., casinos, sports betting facilities such as racetracks, and slots, VLTs, etc., located within casinos) and increased availability of gaming (i.e., number of lotteries, the expansion of internet gambling). Participating in casino gambling, in particular, has been found to be a high risk factor for becoming a pathological gambler.32 There is some evidence that, within Ontario, persons who participate in casino games and VLTs located within casinos have higher rates of problem gambling than those who participate in other forms of gaming.10 A 2010 study by Afifi et al concluded that women were more likely to gamble if it was legally available and therefore the increase of legal forms of gambling results in an increase in women gamblers.33 Specifically, they studied 13 types of gambling and found that Canadian women who gambled using VLTs within casinos or who participated in other casino games had the second and third highest odds of being a problem gambler, respectively.33 Increased proximity to gambling opportunities has been repeatedly linked to an increase in the prevalence of problem and pathological gambling.1;6;9;12;34-36 Research in the United States has shown

A public health perspective on gambling and gaming facilities: a brief literature review

that there is a higher prevalence of problem gambling in areas within 80km of casinos,1;6 with the likelihood of being a pathological or problem gambler being twice the average for persons living within these regions.6 Similarly, a study by Welte et al found that the presence of a casino within 10 miles of a persons home was associated with problem and pathological gambling; specifically, their results found the odds of being a problem or pathological gambler increased by 90%.9 In New Zealand, Pearce et al found that after adjusting for possible confounders, the quartile of the population with the closest access to any type of gambling outlet had odds 2.05 times that of the quartile with the furthest access to gambling outlets of being a problem gambler.34 A study of Ontario university students found a statistically significant difference between the number of problem gamblers at universities closer to a casino than to universities further from a casino.36 Another Ontario study found exposure to gambling facilities (in this case commercial or charity casinos, or slot facilities at racetracks) had a modest but statistically significant effect on the prevalence of problem gamblers.12 These observations are not consistent across all studies; some have found no association between the availability of casinos and the prevalence of problem and pathological gamblers.9 The legalization of gambling and proliferation of casinos around the globe has resulted in numerous natural experiments. In Minnesota between 1990 and 1994, the legalization of the lottery and a large increase in the number of casinos resulted in an increase in the rate of pathological and problem gambling from 2.5% to 4.4%.37 A similar trend was observed in New Zealand where increased usage (62%) of a gambling hotline occurred after the opening of a new casino.38 Cox et al concluded in their study that the rapid and prolific expansion of new forms of legalized gambling ... would be associated with a considerable health cost.35(p213).

Conclusion
The proliferation of legal gambling opportunities in Canada has been accompanied with increased concern over their impact on the community. The prevalence of these unhealthy gambling (problem and pathological gambling), is estimated to be between 2% and 5.5%. Unhealthy gambling can have significant negative impacts on the health of individuals, families and communities. There is a relationship between the availability of gaming facilities and the prevalence of unhealthy gambling.

A public health perspective on gambling and gaming facilities: a brief literature review

References
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A public health perspective on gambling and gaming facilities: a brief literature review

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A public health perspective on gambling and gaming facilities: a brief literature review

35. Cox B, Yu N, Afifi A, Ladouceur R. A national survey of gambling problems in Canada. Can J Psychiatry 2005;50(4):213-7. 36. Adams G, Sullivan A, Horton K, Menna R, Guilmette A. A study of differences in Canadian university students' gambling and proximity to a casino. Journal of Gambling Issues 2007;19:9-17. 37. Emerson M, Laundergan J, Schaeger J. Adult survey of Minnesota problem gambling behavior, a needs assesseent: changes 1990 to 1994. Duluth: Centre for Addictions Studies; 1994. 38. Sullivan S, McCormick R, Sellman J. Increased requests for help by problem gamblers: data from a gambling crisis telephone hotline. N Z Med J 1997;110(1053):380-3.

A public health perspective on gambling and gaming facilities: a brief literature review