What Do GamingWhat Do GamingRegulators Regulate?Regulators Regulate?

A Public Health Perspective on DisorderedA Public Health Perspective on DisorderedGambling & RegulationGambling & Regulation

Richard LaBrie, Ed.D..

North American Gaming Regulators AssociationNorth American Gaming Regulators Association2006 Conference2006 Conference

Scottsdale, ArizonaScottsdale, Arizona

Source of Demands forSource of Demands forRegulationRegulation

The The perceptionperception that gambling is a problem that gambling is a problemand an increasing problem?and an increasing problem?

TheThe perception perception of gamblers as unable to of gamblers as unable toregulate themselvesregulate themselves——as if they have anas if they have anaddiction?addiction?

TheThe perception perception of the gaming industry as of the gaming industry asunable to regulate itself?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 DisorderImpulse Control Disorder

Regulatory problemsRegulatory problems

BiologicalBiological Reward deficiencyReward deficiency NeuroNeuro-genetic vulnerability-genetic vulnerability

Public HealthPublic Health Multidimensional issueMultidimensional issue

On a Public Health PerspectiveOn a Public Health Perspective ““The enduring value of a public healthThe enduring value of a public health

perspective is that it appliesperspective is that it appliesdifferent 'lenses' for understandingdifferent 'lenses' for understandinggambling behaviour, analysing itsgambling behaviour, analysing itsbenefits and costs, as well asbenefits and costs, as well asidentifying strategies for actionidentifying 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), 285-287.(4), 285-287.

••Protect & improve the health ofProtect & improve the health ofpopulationspopulations••Identify proximal & distalIdentify proximal & distal

determinants of diseasedeterminants of disease••biological & behavioral mechanismsbiological & behavioral mechanisms

responsible for diseaseresponsible for disease

••social situations that place people atsocial situations that place people athigher risk for developing diseasehigher risk for developing disease•• Poverty, exposure to toxic substances, access toPoverty, exposure to toxic substances, access to

gambling, opportunities for health caregambling, opportunities for health care

Primary Elements of a PublicPrimary Elements of a PublicHealth PerspectiveHealth Perspective

A Public Health View ofA Public Health View ofCommunicable 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 foundationScientific research is the foundationof public health knowledgeof public health knowledge

2.2. Public health knowledge derives fromPublic health knowledge derives frompopulation-based observationspopulation-based observations

3.3. Public health initiatives are proactivePublic health initiatives are proactive

4.4. Public health perspectives arePublic health perspectives arebalancedbalanced

The Four Principles ofThe Four Principles ofPublic Health PerspectivesPublic Health Perspectives

Science ProvidesScience Providesthe Foundation forthe Foundation for

Public HealthPublic HealthProgramsPrograms

Researchers at Harvard study theResearchers at Harvard study theeffects of casino gambling oneffects of casino gambling on

laboratory rats.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

SE

s

* 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 andCourses of Exposure andAdaptationAdaptation

0

200

400

600

800

1000

1200

'97 '98 '99 '00 '01 '02 '03

Year#

of N

ew

MO

SE

s

Regulatory Consequences ofRegulatory Consequences ofExposure & Adaptation ModelsExposure & Adaptation Models

ExposureExposure Leads to slow response, or under-reactionLeads to slow response, or under-reaction

given the given the ““incubationincubation”” of disease following of disease followingexposureexposure

AdaptationAdaptation Leads to regulatory over-reaction since theLeads to regulatory over-reaction since the

population tends to adjust for the presence ofpopulation tends to adjust for the presence ofthe toxic agentthe toxic agent

Neurobiological Elements

(e.g., Genetic Risk,

Neurobiological

System Risk)

Underlying

Vulnerability

Object

Interaction

Exposure to

Object or Activity

X, Y or Z

Distal Antecedents of the

Addiction Syndrome

Expressions, Manifestations and Sequelae of

Addiction Syndrome

If

Yes

Repeated

Object

Interaction &

Desirable

Subjective

Shifts

Premorbid

Addiction Syndrome

If

Yes

If

Yes

Proximal

Antecedents

(e.g.,

biopsychosocial

events)

e.g., Liver

Cirrhosis

e.g.,

Gambling

Debt

e.g.,

Pulmonary

Carcinoma

e.g.,

Sepsis

Drinking Gambling SmokingIntravenous

Drug UsingExpression

Unique

Manifestations

& Sequelae

Shared

Manifestations

& Sequelae

Immediate

Neurobiological

Consequences

Resulting in Desirable

Subjective Shift

If

Yes

Psychosocial

Elements

(e.g., Psychological and

Social 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, temporal

sequencing of symptom

progression or recovery)

Object Substitution

(e.g., increase in

sedative use during

decrease in opioid use)

Biological Cluster

(e.g., tolerance,

withdrawal,

neuroanatomical

changes, genetic

expressions)

Tertiary Prevention

Secondary PreventionPrimary Prevention

Shaffer, H., LaPlante, D., LaBrie, R., Kidman, R., Donato, A., Stanton, M. (2004) Toward a SyndromeModel 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

severeHealthyGambling Unhealthy

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 aboutthe population

attributes or “set”

“Setting”context

Primary Products of RegulatoryPrimary Products of RegulatoryEffortsEfforts

Hotlines & helpHotlines & helplineslines

AdvertisingAdvertising Alcohol serviceAlcohol service CreditCredit Employee trainingEmployee training

Loss limitsLoss limits Marketing & directMarketing & direct

mailmail SignageSignage Public awarenessPublic awareness Self-exclusionSelf-exclusion Treatment fundingTreatment funding

Source: American Gaming Association (March 2002). Statutes andregulations in commercial casino states concerning responsible gaming.

Classifying the Objects ofClassifying the Objects ofRegulatory ActivitiesRegulatory Activities

InitiationInitiation AwarenessAwareness PreventionPrevention Advertising/MarketingAdvertising/Marketing

Gambling & gambling-related activitiesGambling & gambling-related activities SignageSignage Employee training Employee training –– pathological gambling & education 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

Mic

higan

Mis

souri

New

Jer

sey

Mis

siss

ippi

Iowa

Nev

ada

Louisia

na

Illin

ois

S. Dak

ota

Col

orad

o

India

na

Casino States

Re

gu

lati

on

s

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 inCommercial Casino States Concerning Responsible Gaming.

Regulatory Activities 2002Regulatory Activities 2002

02468

Treat

men

t...

Hel

pline

Sig

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Loss li

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Public

Aw...

Alc

ohol

Mar

ketin

g

Adve

rtis

ing

Em

p. PG p

...

Regulatory Activities

Sta

tes

Colorado Illinois Indiana Iowa

Louisiana Michigan Mississippi Missouri

New Jersey Nevada S. Dakota

Source: American Gaming Association. (2002). Statutes & Regulations inCommercial Casino States Concerning Responsible Gaming.

Targets of Regulatory Activities 2002Targets of Regulatory Activities 2002

0 2 4 6 8

Michigan

Missouri

New Jersey

Iowa

Nevada

Mississippi

Louisiana

Illinois

S. Dakota

Indiana

Colorado

Initiation Gambling Related Activities Consequences

Source: American Gaming Association. (2002). Statutes & Regulations inCommercial Casino States Concerning Responsible Gaming.

Natural History of Gambling:Natural History of Gambling:Targets of Statutes & Regulations in CasinoTargets of Statutes & Regulations in Casino

States (2002)States (2002)

13%

47%

40%Initiation

Gambling

Consequences

Source: American Gaming Association. (2002). Statutes & Regulations inCommercial 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 gamblingpolicies 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 communityPromote 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 publicHealthy gambling guidelines for the public Develop vehicles for early identificationDevelop vehicles for early identification

Screens, education, community resourcesScreens, education, community resources

Develop moderation and abstinence goalsDevelop moderation and abstinence goalsthat can be offered non-judgmentallythat can be offered non-judgmentally

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 MarcarelliMelissa Marcarelli Chrissy ThurmondChrissy Thurmond Christine ReillyChristine Reilly

Iowa Department of Public HealthIowa Department of Public Health Nevada Department of PublicNevada Department of Public

HealthHealth Massachusetts Department ofMassachusetts Department of

Public HealthPublic Health National Center for ResponsibleNational Center for Responsible

GamingGaming Missouri Port AuthorityMissouri Port Authority National Institute on AlcoholNational Institute on Alcohol

Abuse and AlcoholismAbuse and Alcoholism ValueOptionsValueOptions betandwin.combetandwin.com Massachusetts Driving Under theMassachusetts Driving Under the

Influence of Liquor TreatmentInfluence of Liquor TreatmentProgramProgram

Massachusetts Council onMassachusetts Council onCompulsive GamblingCompulsive Gambling

Wisconsin Association on AlcoholWisconsin Association on Alcoholand Other Drug Abuseand Other Drug Abuse

For more informationFor more information……

www.divisiononaddictions.orgwww.divisiononaddictions.org Division on AddictionsDivision on Addictions’’ website website Publications, presentations, and current projectPublications, presentations, and current project

descriptions availabledescriptions available

www.basisonline.orgwww.basisonline.org Brief science reviews and editorials on current issuesBrief science reviews and editorials on current issues

in the field of addictionsin the field of addictions Addiction resources available, including self-helpAddiction resources available, including self-help

toolstools

rlabrie@hms.harvard.edurlabrie@hms.harvard.edu