“Replacement problem gamblers”

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On 24 April 2014  I sent to the Director for Policy,  Development and External Affairs of the NYS Gaming Commission the following  e-note with two attachments:

Dear Sir,

Attached are two documents I earnestly hope the Chairman and all the Commissioners will read carefully and discuss with the  GFLB.  Both are about “problem gambling,” the subject of the April 9 forum convened by the Gaming Commission. Watching the videotape and reading the transcript (everyone should thank the GC for providing these so fast) I saw  that “problem gambling” was an elusive term.  The extreme importance to the casino economy of net losses from problem gamblers was nowhere mentioned except when the speaker from Caesars deflected  the issue.  Yet around the “central statistic of casino revenues,” on which I have written to the Commission, is the “central dilemma” of regulation: the better the regulation is at preventing problem gambling, the lower is the casinos’ profit margin.

Selected prevalence statistics were presented as if they are the be-all and the end-all of gambling behavior studies.  They are about all we have, but a poor stand-in for what we really want to know about time trends in social impacts, i.e.  incidence and duration.  Under the placid surface of what looks like stable prevalence,  much new damage continues; as problem gamblers recover or die, new ones must be recruited to take their places.

As I have offered before, I am[ready]  almost any time to meet with the Commissioners and staff to explain the critiques in more detail and to talk about “the central statistic.”

Thank you for your attention.

Sincerely, etc.

Stephen Q. Shafer, MD, MA,  MPH Chairperson, Coalition Against Gambling in New York 917 453 7371 http://cagnyinf.org

To no one’s surprise,  the Commission has not responded to my unsolicited comments. Does that mean the Commissioners have all accepted  the ” adaptation hypothesis” [summarized in the next paragraph]   that  gambling expansion has  little long-term population impact?  If they have, ” this  was a grievous fault,”  but unless NYS media call them out  sharply  on it,  the Commission will not have to answer it grievously. If,  as I hope,  they have not bought it,  one sign will be that  the  Facilities Location Board  questions searchingly all applicants for a casino license on  what they will really do that will really  stop new cases of problem gambling.

Gentlemen of the Gaming Commission, how say you?

[Scientists from the Division on Addictions of the Cambridge Health Alliance have proposed an “adaptation hypothesis,” which acknowledges that new gambling opportunities may lead to a temporary increase in prevalence of problem gambling  for the surrounding population. Then, so goes the hypothesis, novelty fades,  individuals become more “responsible” in their gambling behaviors and  the crest subsides.]

One of the two attachments, slightly revised a month later,  is below. It begins with Summary.   It concerns the public health profile  of “problem gambling.”    The other, related to an operational definition of “problem gamblers”  and to their fiscal significance,  will soon be posted on the CAGNY web site.

Summary: “Problem gambling” is not a fixed uniform term. In his introduction to the April 9 forum on Problem Gambling, Dr. Gearan seems to take it, as I do, to mean both strata of gambling disorder combined, not just the less severe stratum often referred to as “problem gambling.” Statistics on the prevalence of “problem gambling” or its subgroup “pathological gambling” are often used to reassure policy-makers that gambling expansion has not worsened problem or pathological gambling. These statistics can be challenged on several grounds, but even if prevalence as a proportion of the population is truly unchanged in the long term, there are hundreds of thousands of new cases nationally hidden in it, millions of individuals affected. To keep prevalence stable there have to be new pathological gamblers brought on to take the place of those who died or entered recovery. Opponents of big tobacco use the term “replacement smokers.”  We extend this concept to “replacement” problem gamblers.   Tobacco companies need replacement smokers; society does not.  Casinos need replacement problem gamblers; society does not.  Quite the reverse.

Introduction  In the April 9th 2014 Problem Gambling forum hosted by the New York State Gaming Commission two speakers, Dr. Sarah Nelson and Ms Christine Reilly, used lack of change over time in “the prevalence of problem gambling”   to argue that expanded gambling opportunities do not increase endemic harms to public health. I will challenge that premise as an epidemiologist by digging into the population dynamics of “prevalence.”  With problem gambling, as with most chronic conditions, prevalence is more easily measured than the rate at which new cases develop. That does not mean it’s a perfectly valid marker of causation.  It hides new cases, the replacement problem gamblers that predatory gambling must endlessly cultivate to keep profits high.   To speak of the prevalence of “problem gambling” requires first defining the latter term. In the second and third sections of this narrative I will talk about the pitfalls of prevalence to assess “problem gambling” in a population.

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“Measure Something:” Prevalence of Pathological and of Problem Gamblers

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Most American adults gamble not at all (20-30%) or so little they get no damage from it. The gigantic social costs of legalized gambling move almost entirely through current “pathological gamblers,” who enmesh and drain their families, employers, employees and associates, and   through current “problem gamblers.”   Problem gamblers, more common,  impose each a smaller social cost. The two groups combined make up 4 % of the U.S. and Canadian adult (>18) population.1   Lower estimates for prevalence are also in the literature. 2, 3     CAGNY reports  use the 4% from the update of the Shaffer et al 1997 meta-analysis 4  as it is based on over a hundred studies, not a single survey.

Pathological gamblers (addicts) and problem gamblers combined generate almost all the costs of legalized gambling. Pathological (addicted) gamblers make up conservatively 1.14% of adults in North America; problem gamblers, at least 2.8%. In the U.S. that’s 2.5 million pathological gamblers (addicts) and 6.5 million problem gamblers.

Prevalence is not a good marker of the rate at which new cases occur. If it seems  stable over time, that does not mean no new  problem gamblers are forming. Not at all. To maintain the same prevalence of current pathological gambling, replacement pathological gamblers must  take the place of those who have recovered or died or disappeared.

Prevalence is usually given as the proportion (can be %) of a population that has the condition of interest (in this case a certain level of gambling) at a given moment or at some point in a time interval.  Prevalence can also be a count. It is not the same thing as incidence. Incidence is a rate,  the number of new cases in a time divided by the number at risk. It too can be correctly given as a count of cases.  Incidence, a rate,  must  be written per <time interval>  e.g  ” per year.”

Prevalence is governed by incidence  and  duration. Cases prevalent at a certain time will not be all the same ones as at a different time. Individuals leave the active ( = “past-year”) prevalence pool by out-migration, recovery, death, incarceration or disabling illness. New cases enter the pool. If prevalence, accurately measured,   is  steady over (say)  ten years,  that stability requires  replacement problem gamblers in the stead of those who died; or recovered (one estimate is that 1/3 recover 5 ); or went to jail (more than half of PGs commit prosecutable crimes); or moved to another country. The lifetime prevalence pool is depleted only by death or out-migration.

There are very few figures on incidence of pathological or problem gambling in adults, though in adolescents and college students these are available, and horrifying.  Estimates of incidence of pathological gambling in North American adults must be drawn from changes in prevalence, full of pitfalls. Rapid climbs in past-year or even lifetime prevalence imply relatively high incidence; rapid drops suggest high rates of recovery or death combined with low replacement.

References and notes to “Prevalence of Pathological and of Problem Gamblers”

1. Shaffer HJ, Hall MN Updating and Refining Prevalence Estimates of Disordered Gambling Behaviour in the United States and Canada. Canadian J Pub Health 2001 92(3): 168-172

2. Gerstein D et al Gambling Impact and Behavior Study. Research done by NORC for NGISC http://govinfo.library.unt.edu/ngisc/reports/gibstdy.pdf .

3. Petry N, Stinson FS, Grant B Comorbidity of DSM-IV Pathological Gamblers and Other Psychiatric Disorders. J Clin Psychiatry 2005. 66(5): 566-574

[ NOTE:In this report the lifetime prevalence of pathological gambling is 0.6% and of problem, 2.3%. A past-year figure would be lower.]

4. Shaffer HJ, Hall MN, Vander Bilt J Estimated Disordered Gambling Behavior in the United States and Canada Report to National Gambling Impact Study Final Report 1999  https://divisiononaddictions.org/html/publications/meta.pdf

Using these past-year prevalence figures the Shaffer et al study projected the following figures in millions of persons who were in each category (based on US pop in 1997)

Table 1. Number of persons classed as Problem or Pathological Gamblers, by age group,  USA , millions

 

ADULT                                  YOUTH (age 16-17)   ADULT & YOUTH

Prob     Pathol Both                Prob     Pathol Both                Prob     Pathol Both

5.3       2.2       7.5                   5.7       2.2       7.9                   11        4.4      15.4

IMPORTANT NOTE On p. 43 of Shaffer et al are figures showing an increase in the prevalence of past-year level 3  (abbreviated here to PYL3) between the earlier years covered by their meta-analysis (1977-1993) and the most recent three years (1994-1997). PYL3 in adults went from 0.84% to 1.29%, a statistically significant increase (p<.05). Comparing the same two epochs, lifetime level 2 in adults went from 2.93% to 4.88% (p < .05). The absolute increase in prevalence of PYL3 in adults was 0.45% , the relative increase 154%. When the authors merged all the studies, earlier and later, the higher prevalence figure (1.29%) was lost to view. The lower figure of 1.14 is probably too conservative.

A later paper (Shaffer and Hall Can J Pub Health 2001, referenced above as ref 1 found strong evidence that PYL3 continued to rise in the last years of the study interval. The authors updated the library of studies to review, adding ones published since 1997 and also some 91 studies that had never been published, furnished by their authors. 139 studies with at least one prevalence estimate (some compared two instruments) were analyzed for the 2001 paper. For adults only  Past year level 3 1.46%  lifetime level 3 1.92%.  There was a  positive correlation (r = .313, p<.05) for later year and higher prevalence. The authors found fifteen geographic areas in which earlier and later estimates had been done by the same methods. PYL3 averaged 1.02% in the earlier look, 1.33% in the second (p < .05)

5. Slutske WS Natural Recovery and Treatment –Seeking in Pathological Gambling. Am J. Psychiatry 2006: 163:297-502  The researcher looked at the past-year experience of the 201 persons who had met criteria for lifetime pathological gambling in one of two surveys, found that about a third no longer met criteria for the preceding year. The two surveys are in refs 2 and 3

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