Hold ’em Harmless?


The following letter was sent by US mail on 26 October 2015 to the Delhi District office of State Senator John J. Bonacic.  An electronic version  with attachment was transmitted to the  Senator’s  e-mail three days later.



Dear Senator Bonacic,

At the hearing you held Sept 9 regarding S5302 there was good news: you gave at least a little time to the important question of whether legalizing i-poker would have an impact on problem gambling and gambling addiction. The bad news was that you readily accepted a “negdec”   from Mr Pappas of the Poker Players Alliance. I fear your questioning was to get this assurance of no harm onto the record.

Your questioning of Mr Pappas did not show the trial lawyer skills that Mr Featherstonaugh accorded you later in the hearing. Was this just a lapse in preparation, or was it deliberate? Whichever it was, your “OK” to Mr Pappas’s reply surely gave most listeners the false impression that internet gambling — of all kinds – has been well-studied and found not to be worse in any dimension for individuals or populations than other kinds of gambling. Not so.

I would be glad to meet with you and your staff to go over some basic principles of epidemiology and public health that should be applied to the important work you and your colleagues do. They are explained in the enclosed 12-page critique. Sad to say, the approach in the September hearing to this basic science  is no more valid than evaluating a corporation by whether it declared a profit or loss in the most recent annual report.


Stephen Q. Shafer MD MPH

Chairperson,  Coalition Against Gambling in New York  917 453 7371

Below is the critique that was enclosed with the cover letter

Considerations of Internet Problem Gambling in the New York State Senate i-Poker Hearings of September 9 2015: an Epidemiologist’s Critique

Stephen Q. Shafer MD MA MPH                                              27 October 2015


The author is a retired Clinical Professor of Neurology, Columbia University and Chairperson of Coalition Against Gambling in New York, a non-profit all-volunteer organization registered in Buffalo.


During the Sept 9 2015 hearing on legalizing i-poker held by Senator Bonacic there was scant mention of the potential for i-poker or other forms of i-gambling to cause addiction or problem gambling or to sustain these conditions when they had developed in another setting such as a b and m [bricks and mortar] casino. Below is the nearest approach.

At about 15:50 Mr Bonacic, chairing, asked Mr Pappas, CEO of the Poker Players Alliance and the first person to testify, “Is there a ratio for the amount of people that play on line poker, gaming, as opposed to those that get addicted? Is it one in three hundred, one in five hundred?   Is it ascertainable?”

Senator Bonacic seems here to be groping for the prevalence of gambling addiction among persons who do i-poker or i-“gaming.” I expect he meant to make the ratio as he set it up  500 to one, not one in 500. He is certainly leading the witness towards a very low proportion of addicted gamblers among all on-line gamblers.  Note also that the question does not separate poker from other types of i-gambling. This is likely intentional, to blur distinctions in readiness for the transition I think he and associates plan, from two particular forms of i-poker to all forms of casino-type “gaming” on the internet and ultimately to i-betting on sports.

 Mr Pappas responded that he didn’t have notes in hand but that his written testimony gave backup. He summarized,    “There is not a discernible increase, not any increase.” Mr. Bonacic replied “OK. ”

Note well: Mr Pappas did not answer the question Senator Bonacic asked, which was about a “ratio,” not an increase. His response belonged to a question not put. Perhaps he had been expecting something like one of the following:

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Caesars at Woodbury: Problem Gambling ? No Problem







Summary: This is a critique of Attachment IX.A.2.a_A2  in  section  07 – IX.A. Assessment of Local Support and Mitigation Local Impact  of the  application by Caesars Entertainment to the New York State Gaming Facilities Location Board.    Being an epidemiologist and physician familiar with problem gambling as a public health problem,  I found  Attachment IX.A.2.a_A2  extremely biased in downplaying,  to near zero.  the possible health impacts  of a new Woodbury Casino.   The report asserts  as follows:

  • no socio-economic costs of pathological gambling and problem gambling warrant $ consideration, as none can be quantified so that all parties are close to agreement.
  • making casinos more convenient hardly  increases the prevalence of pathological gambling and problem gambling in the surrounding population in the long run.
  • the only population within a 50 mile radius of Woodbury that is  at theoretical  risk of having even a temporary surge in prevalence of pathological gambling and problem gambling  is that of Orange, Dutchess and Putnam Counties.
  • efforts by Caesars elsewhere to address “problem gambling” have been highly successful and will minimize “problem gambling” in southern New York State.

The  report greatly understates the possibility of harm to residents of the region due to a casino in Woodbury to residents of the region.  This essay addresses the first three  points in the above order.  The fourth  I have discussed in an e-mail to the NYS Gaming Commission last April.


In reading the Caesars Entertainment Inc application for a Woodbury casino I focused as a physician versed in public health  on the 40- page report   Study of Addiction and Public Health Implications of a Proposed Casino and Resort in Woodbury New York by Bo J. Bernhard Ph.D., Khalil Philander Ph.D., and Brett Abarbanel Ph.D.

The authors are all experienced consultants for gambling-related  enterprises. Two are senior members of the International Gaming Institute (IGI) at University of Nevada at Las Vegas. This is a highly polished presentation by experts who know the field but hide large tracts of it from view.   It  dismisses or never mentions four crucial facets of the ecology of pathological gambling and problem gambling. The report basically concludes that

  • socio-economic costs of pathological gambling and problem gambling don’t warrant consideration, as none can be quantified so that all parties are close to agreement.
  • making casinos more convenient does not much increase the prevalence of pathological gambling and problem gambling in the surrounding population in the medium  run of 2 to 4 years.
  • the only population within a 50 mile radius of Woodbury that is now under-served by racinos or casinos (and hence at theoretical  risk of having even a temporary surge in prevalence of pathological gambling and problem gambling) is that of Orange, Dutchess and Putnam Counties.
  • efforts by Caesars elsewhere to address “problem gambling” have been highly successful and can be relied on to minimize “problem gambling” in southern NY

The report nowhere mentions a statistic often cited by opponents of predatory gambling but never addressed head-on by casino advocates and never refuted: 40-50% of revenue at the average casino comes from pathological and problem gamblers, who comprise perhaps 12-15% of its customers, maybe 4% of all adults. [ http://cagnyinf.org/wp/april-9-2014-central-stat-of-casino-revenues] For the casino lobby to refute the statistic (if it is refutable) they would have to acknowledge that they can spot pathological and problem gamblers among their “visitors” while those persons are still active customers. This means before the person has loudly threatened suicide within an employee’s hearing or left town suddenly or thrown an ugly scene on the “gaming floor” or been arraigned or jumped.

Casinos will not acknowledge they have any  ability to spot problem or pathological gambling signs and symptoms that are not florid and end-stage. Why not? To move in even gently on such persons would risk offending them so they would go elsewhere or sending them to premature recovery before they have been “played to extinction.” [ https://www.youtube.com/watch?v=9C2BPZYLW_U ] .  To recognize the problem gamblers before they are end-stage yet not do anything for them  would reveal how insincere are the “preventive measures.” .

The casino cartel does not deny that its net revenues follow the Pareto principle: most come from a small proportion of gamblers. What casino promoters won’t say is what proportion on the average of that small proportion are pathological gamblers or problem gamblers. The promoters just do not want to know who among their customers is a problem gambler or pathological gambler until the gambler hits bottom or worse.   Promoters and detractors alike recognize that not everyone who loses a lot of money over time at casinos is a problem gambler. Anti-casino activists hold that most are; the American Gaming Association counters that most are affluent people having fun with their disposable income.

Assuming the central statistic is close to truth, casinos are not motivated to sincerely counter problem gambling and pathological gambling.  A successful effort to do so would lower their revenues by 40-50%.  Nor is government motivated; lower casino gross gaming revenues   would reduce  government’s share  by a like amount.

The report prepared for Caesars (in this no different from all the literature on problem gambling) also does not recognize that “unchanging prevalence” of problem and pathological gambling requires the formation of replacement problem gamblers and pathological gamblers to fill the shoes of those who have recovered, died, moved far away or are no longer free-living. What might appear a steady state is built on creating new problem gamblers. The more effective  the casino is at encouraging current problem gamblers and pathological gamblers into lasting recovery before they have fiscally and emotionally wiped out themselves and and ten people around them, the faster it must generate replacement problem and pathological gamblers to keep up its high profit margins.

I will now cover the first three bullet points above in more detail. The fourth bullet point I wrote about in the above-mentioned letter to the Gaming Commission.

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“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






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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