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What Do Gaming What Do Gaming Regulators Regulate?Regulators Regulate?
A Public Health Perspective on Disordered A Public Health Perspective on Disordered Gambling & RegulationGambling & Regulation
Richard LaBrie, Ed.D..
North American Gaming Regulators AssociationNorth American Gaming Regulators Association2006 Conference2006 Conference
Scottsdale, ArizonaScottsdale, Arizona
Source of Demands for Source of Demands for RegulationRegulation
The The perceptionperception that gambling is a that gambling is a problem and an increasing problem?problem and an increasing problem?
TheThe perception perception of gamblers as of gamblers as unable to regulate themselves—as if unable to regulate themselves—as if they have an addiction?they have an addiction?
TheThe perception perception of the gaming of the gaming industry as unable to regulate itself?industry as unable to regulate itself?
Selected ModelsSelected Models
Moral turpitudeMoral turpitude PsychologicalPsychological
Bad JudgmentBad Judgment BehavioralBehavioral CognitiveCognitive Cognitive-BehavioralCognitive-Behavioral AdaptationAdaptation
SocialSocial EconomicEconomic ExposureExposure
Psycho-SocialPsycho-Social Psycho-economicPsycho-economic Impulse Control Impulse Control
DisorderDisorder Regulatory problemsRegulatory problems
BiologicalBiological Reward deficiencyReward deficiency Neuro-genetic Neuro-genetic
vulnerabilityvulnerability Public HealthPublic Health
Multidimensional Multidimensional issueissue
On a Public Health PerspectiveOn a Public Health Perspective ““The enduring value of a public The enduring value of a public
health perspective is that it applies health perspective is that it applies different 'lenses' for understanding different 'lenses' for understanding gambling behaviour, analysing its gambling behaviour, analysing its benefits and costs, as well as benefits and costs, as well as identifying strategies for action”identifying strategies for action” (p. (p. 286).286).
Harvey A. SkinnerHarvey A. Skinner (1999). Gambling: achieving the right balance. (1999). Gambling: achieving the right balance. Journal of Gambling Studies, 15Journal of Gambling Studies, 15(4), 285-(4), 285-
287.287.
•Protect & improve the health of Protect & improve the health of populationspopulations
•Identify proximal & distal Identify proximal & distal determinants of diseasedeterminants of disease•biological & behavioral mechanisms biological & behavioral mechanisms
responsible for diseaseresponsible for disease
•social situations that place people at social situations that place people at higher risk for developing disease higher risk for developing disease • Poverty, exposure to toxic substances, Poverty, exposure to toxic substances,
access to gambling, opportunities for health access to gambling, opportunities for health carecare
Primary Elements of a Public Primary Elements of a Public Health PerspectiveHealth Perspective
A Public Health View of A Public Health View of Communicable DiseaseCommunicable Disease
Environment
Host
Agent
Vector
A Public Health View ofA Public Health View ofDisordered GamblingDisordered Gambling
Environment
Gambler
Game
Money
1.1. Scientific research is the foundation of Scientific research is the foundation of public health knowledgepublic health knowledge
2.2. Public health knowledge derives from Public health knowledge derives from population-based observationspopulation-based observations
3.3. Public health initiatives are proactivePublic health initiatives are proactive
4.4. Public health perspectives are Public health perspectives are balancedbalanced
The Four Principles ofThe Four Principles ofPublic Health PerspectivesPublic Health Perspectives
Science Provides Science Provides the Foundation for the Foundation for
Public Health Public Health Programs Programs
Researchers at Harvard study Researchers at Harvard study the effects of casino gambling the effects of casino gambling
on laboratory rats.on laboratory rats.
Epidemic SchematicEpidemic Schematic
Number of Enrolled Self-Excluders*Number of Enrolled Self-Excluders*
0
200
400
600
800
1000
1200
'97 '98 '99 '00 '01 '02 '03
Year
# o
f N
ew
MO
SEs
* 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.org
Courses of Exposure and Courses of Exposure and AdaptationAdaptation
0
200
400
600
800
1000
1200
'97 '98 '99 '00 '01 '02 '03
Year#
of N
ew M
O S
Es
Regulatory Consequences of Regulatory Consequences of Exposure & Adaptation ModelsExposure & Adaptation Models
ExposureExposure Leads to slow response, or under-Leads to slow response, or under-
reaction given the “incubation” of reaction given the “incubation” of disease following exposuredisease following exposure
AdaptationAdaptation Leads to regulatory over-reaction since Leads to regulatory over-reaction since
the population tends to adjust for the the population tends to adjust for the presence of the toxic agentpresence of the toxic agent
Neurobiological Elements(e.g., Genetic Risk,
NeurobiologicalSystem Risk)
UnderlyingVulnerability
ObjectInteraction
Exposure toObject or Activity
X, Y or Z
Distal Antecedents of theAddiction Syndrome
Expressions, Manifestations and Sequelae ofAddiction Syndrome
IfYes
RepeatedObject
Interaction &DesirableSubjective
Shifts
PremorbidAddiction Syndrome
IfYes
IfYes
ProximalAntecedents
(e.g.,biopsychosocial
events)
e.g., LiverCirrhosis
e.g.,Gambling
Debt
e.g.,PulmonaryCarcinoma
e.g.,Sepsis
Drinking Gambling SmokingIntravenousDrug UsingExpression
UniqueManifestations
& Sequelae
SharedManifestations
& Sequelae
ImmediateNeurobiologicalConsequences
Resulting in DesirableSubjective Shift
IfYes
PsychosocialElements
(e.g., Psychological andSocial Risk Factors)
Treatment Non-specificity(e.g., CBT,
pharmacotherapy)
Social Cluster(e.g., deviant behaviors,delinquency, criminality,
social drift)
Psychological Cluster(e.g., psychopathology &
comorbidity)
Natural History(e.g., exposure, relapse
rates, temporalsequencing of symptomprogression or recovery)
Object Substitution(e.g., increase in
sedative use duringdecrease in opioid use)
Biological Cluster(e.g., tolerance,
withdrawal,neuroanatomicalchanges, genetic
expressions)
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.
NonGambling
Ran
ge o
f B
eh
avio
rsFramework for Public Health
Action
Range of Interventions
Primary prevention Secondary prevention Tertiary prevention
Health Promotion
Harm Reduction
intensiveTreatmentbrief
Range of Gambling Problemsnone
mild
moderate
severeHealthy
GamblingUnhealthy
Public Health Regulatory TargetsPublic Health Regulatory Targets
People & GroupsPeople & Groups Population of gamblersPopulation of gamblers Gaming industryGaming industry
Gambling activitiesGambling activities Exposure & access to gamblingExposure & access to gambling
Gambling settingsGambling settings Industry growthIndustry growth Activities within gambling settingActivities within gambling setting Activities around gambling settingActivities around gambling setting
Activities or “games”
Expectations about the population
attributes or “set”
“Setting” context
Primary Products of Regulatory Primary Products of Regulatory EffortsEfforts
Hotlines & help Hotlines & help lineslines
AdvertisingAdvertising Alcohol serviceAlcohol service CreditCredit Employee Employee
trainingtraining
Loss limitsLoss limits Marketing & Marketing &
direct maildirect mail SignageSignage Public awarenessPublic awareness Self-exclusionSelf-exclusion Treatment Treatment
fundingfundingSource: American Gaming Association (March 2002). Statutes and regulations in commercial casino states concerning responsible gaming.
Classifying the Objects of Classifying the Objects of Regulatory ActivitiesRegulatory Activities
InitiationInitiation AwarenessAwareness PreventionPrevention Advertising/MarketingAdvertising/Marketing
Gambling & gambling-related activitiesGambling & gambling-related activities SignageSignage Employee training – pathological gambling & educationEmployee training – pathological gambling & education Alcohol serviceAlcohol service Credit restrictionsCredit restrictions Loss limitsLoss limits
Consequences of GamblingConsequences of Gambling Self-exclusionSelf-exclusion HelplineHelpline TreatmentTreatment
Regulatory Activities 2002Regulatory Activities 2002
02468
Casino States
Reg
ula
tio
ns
Helpline Advertising
Alcohol Credit
Employee Training Employee PG prevention
Loss limits Marketing
Signage Public Awareness
Self-exclusion Treatment funding
Source: American Gaming Association. (2002). Statutes & Regulations in Commercial Casino States Concerning Responsible Gaming.
Regulatory Activities 2002Regulatory Activities 2002
02468
Regulatory Activities
Sta
tes
Colorado Illinois Indiana Iowa
Louisiana Michigan Mississippi Missouri
New Jersey Nevada S. Dakota
Source: American Gaming Association. (2002). Statutes & Regulations in Commercial Casino States Concerning Responsible Gaming.
Targets of Regulatory Activities 2002Targets of Regulatory Activities 2002
0 2 4 6 8
MichiganMissouri
New JerseyIowa
NevadaMississippi
LouisianaIllinois
S. DakotaIndiana
Colorado
Initiation Gambling Related Activities Consequences
Source: American Gaming Association. (2002). Statutes & Regulations in Commercial Casino States Concerning Responsible Gaming.
Natural History of Gambling:Natural History of Gambling:Targets of Statutes & Regulations in Casino Targets of Statutes & Regulations in Casino
States (2002)States (2002)
13%
47%
40% Initiation
Gambling
Consequences
Source: American Gaming Association. (2002). Statutes & Regulations in Commercial Casino States Concerning Responsible Gaming.
Public Health StrategiesPublic Health Strategies
Prevent gambling related problemsPrevent gambling related problems Promote healthy attitudes, behaviors Promote healthy attitudes, behaviors
& policies toward gambling& policies toward gambling Protect vulnerable groupsProtect vulnerable groups
Public Health PrinciplesPublic Health Principles
Make community level prevention a priorityMake community level prevention a priority Promote mental health & build community Promote mental health & build community
capacity for mental healthcapacity for mental health CognitiveCognitive EmotionalEmotional
Foster personal and social responsibilityFoster personal and social responsibility PoliciesPolicies PracticesPractices
Incorporate harm reduction strategiesIncorporate harm reduction strategies
Harm Reduction StrategiesHarm Reduction Strategies
Healthy gambling guidelines for the Healthy gambling guidelines for the publicpublic
Develop vehicles for early Develop vehicles for early identificationidentification Screens, education, community Screens, education, community
resourcesresources Develop moderation and abstinence Develop moderation and abstinence
goals that can be offered non-goals that can be offered non-judgmentallyjudgmentally
Special ThanksSpecial Thanks Dr. Howard ShafferDr. Howard Shaffer Dr. Richard LaBrieDr. Richard LaBrie Dr. Sarah NelsonDr. Sarah Nelson Rachel KidmanRachel Kidman Tony DonatoTony Donato Michael StantonMichael Stanton Allyson PellerAllyson Peller Dr. Mark AlbaneseDr. Mark Albanese Bree TseBree Tse Siri OdegaardSiri Odegaard Sarbani HazraSarbani Hazra Gabriel CaroGabriel Caro Melissa Marcarelli Melissa Marcarelli Chrissy ThurmondChrissy Thurmond Christine ReillyChristine Reilly
Iowa Department of Public Iowa Department of Public HealthHealth
Nevada Department of Public Nevada Department of Public HealthHealth
Massachusetts Department of Massachusetts Department of Public HealthPublic Health
National Center for National Center for Responsible GamingResponsible Gaming
Missouri Port AuthorityMissouri Port Authority National Institute on Alcohol National Institute on Alcohol
Abuse and AlcoholismAbuse and Alcoholism ValueOptionsValueOptions betandwin.combetandwin.com Massachusetts Driving Under Massachusetts Driving Under
the Influence of Liquor the Influence of Liquor Treatment ProgramTreatment Program
Massachusetts Council on Massachusetts Council on Compulsive GamblingCompulsive Gambling
Wisconsin Association on Wisconsin Association on Alcohol and Other Drug AbuseAlcohol and Other Drug Abuse
For more information…For more information…
www.divisiononaddictions.orgwww.divisiononaddictions.org Division on Addictions’ websiteDivision on Addictions’ website Publications, presentations, and current Publications, presentations, and current
project descriptions availableproject descriptions available www.basisonline.orgwww.basisonline.org
Brief science reviews and editorials on current Brief science reviews and editorials on current issues in the field of addictionsissues in the field of addictions
Addiction resources available, including self-Addiction resources available, including self-help toolshelp tools
[email protected]@hms.harvard.edu
