PREVENTION OF PROBLEM GAMBLING: A COMPREHENSIVE REVIEW OF THE EVIDENCE AND IDENTIFIED BEST PRACTICES

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1 PREVENTION OF PROBLEM GAMBLING: A COMPREHENSIVE REVIEW OF THE EVIDENCE AND IDENTIFIED BEST PRACTICES Dr. Robert Williams Faculty of Health Sciences & Alberta Gambling Research Institute University of Lethbridge Many Ways to Help Conference Victorian Responsible Gambling Foundation Melbourne, Victoria October 22, 2014

2 Collaborators Ms. Bev West Former Research Associate, Faculty of Health Sciences, University of Lethbridge, Lethbridge, Alberta Mr. Rob Simpson Former CEO, Ontario Problem Gambling Research Centre, Guelph, Ontario

3 EDUCATIONAL INITIATIVES

4 Information/Awareness Campaigns e.g., know your limits ; gamble responsibly ; true odds; dispelling fallacies; help lines; signs of PG on gambling product; posters at venue; radio/tv; websites; presentations at schools Mixed results showing these messages can temporarily improve knowledge and change attitudes However, a) most people don t attend to them and b) effect on gambling behaviour fairly minimal (except for helpline calls and presentation to treatment, which reliably increases) In other prevention fields, behavioural change uncommon, and only occurs if info is personally relevant, behaviour easy to change, and consequences of not changing are significant (e.g., cholesterol, sodium, HIV testing)

5 On-Site Information/Counselling Centres (RGICs) Info about gambling/pg & referral to, or actual provision of counseling Since 2002; Australia, Canada, S. Korea, other countries High patron awareness, but low utilization 61,400 visits in Ontario vs 200,000,000 customers 8,000 visits for Manitoba vs 14,600,000 customers Mostly provide info on PG and make treatment referrals Information rated as helpful, but very low follow-through on treatment referrals, and no impact on gambling behaviour

6 School-Based Statistical Instruction Teaching expected value, odds and mathematical principles underlying gambling (and either directly or indirectly dispelling gambling fallacies) Several studies, with mixed results Reliable impacts on knowledge and gambling fallacies, inconsistent impacts on subsequent gambling behaviour

7 Comprehensive School- Based Prevention Programs Don t Bet on It in Ontario; Wanna Bet in Minnesota; Stacked Deck in Alberta, New York, North Carolina statistical knowledge; gambling fallacies; addictive nature of gambling; building self-esteem, social problem-solving; peer resistance training Only 4 empirical studies: Reliable impacts on knowledge and gambling fallacies, inconsistent impacts on behaviour (Stacked Deck only program to achieve behavioural change) School-based prevention programs in other fields (smoking, drug use, etc.) have found similar mixed results

8 POLICY INITIATIVES Restrictions on the General Availability of Gambling

9 Restricting # of Gambling Venues Good support by virtue of positive correlation between local PG rate and proximity to gambling venues in U.S., N.Z., Australia & Canada This relationship strongest for casinos: Canadian Provincial PG Prevalence vs. Venues per Capita Casinos r =.75* Bingo Licenses r =.56 Horse Racing Venues r =.40 EGM Locations r = -.01 Lottery Outlets r = -.50 Opening of new venues has also generally been associated with subsequent increases in rates of PG

10 Restricting More Harmful Types of Gambling EGMs, casino table games, Internet gambling Strong relationship between EGMs per capita and PG rates within countries (r =.66* Canada; r =.60 Australia) However, no correlation between countries (tau b = -.18) Modest EGM reductions do not produce much effect on PG rates (e.g., Victoria; S. Australia; Nova Scotia) However, total EGM elimination in South Dakota (1994) South Carolina (2000), and Norway (2007) did reduce PG. Prevalence of Internet problem gambling directly related to its legal availability

11 Restricting the Number of Gambling Formats One of the strongest associations with PG is number of gambling formats person engages in Reducing/restricting the number of gambling formats is a theoretically sensible strategy No empirical evidence

12 Limiting Gambling to Gambling Venues Theoretically sensible, but lacks empirical support In Canada, no relationship between # EGM locations per capita and provincial PG rates (r =.01). In U.S. no significant difference in PG prevalence in 5 states with EGM s outside gambling venues (2.3%) vs states that only have EGM s within dedicated gambling venues (2.2%) In Europe, EGMs found outside gambling venues in most countries, yet Europe tends to have lower rates of PG However, part of the explanation is that jurisdictions with this policy tend to increase number of dedicated gambling venues to compensate (e.g., France has 197 casinos, California has 162, etc.).

13 Restricting the Location of Gambling Venues Individual vulnerability one of the strongest predictors of PG. Historically, casinos were always kept away from major urban centers. Worldwide, PG and other addictions more often found in poorer neighborhoods In Canada, provincial PG rates strongly correlated with proportion of the provincial population with Aboriginal ancestry (r =.94*) as well as provincial rates of alcohol dependence (r =.71*).

14 Limiting Gambling Venue Hours Common policy in some countries Has good support in the alcohol policy field Reduction in hours in jurisdictions that have done this (i.e., Nova Scotia, Australia) had modest effects on PG expenditure (probably because the magnitude of the reduction was fairly small)

15 POLICY INITIATIVES Restrictions on Who can Gamble

16 Prohibition of Youth Gambling Despite almost worldwide underage prohibition: underage youth may still have significant rates of PG countries with permissive attitudes toward youth gambling (U.K., Nordic countries), have lower rates of adult PG Could early exposure have beneficial effects? Important lessons from the alcohol field (China, southern Europe, Israel vs. France & Aboriginal populations) showing that early exposure counterproductive unless associated with extended modeling of appropriate use

17 Raising Legal Age for Gambling Currently ranges from 16 to 25 depending on the jurisdiction and type of gambling year olds have the highest rates of PG In the alcohol field, it is clear that increasing the legal age significantly decreases use and abuse Norway found a significant decrease in EGM use when legal age increased from 16 to 18

18 Restricting Venue Entry to Non-Residents Historically, a common policy Currently: Bahamas, Malaysia, Vietnam, Nepal, Papua New Guinea, Australia (online casinos), Slovenia (4 times/month), S. Korea (1/16 casinos) Theoretically sound, but very little evidence However, casino gambling uncommon in S. Korea (i.e., < 5% of the population), and rates of PG much lower than other Asian jurisdictions (i.e., Singapore, Hong Kong, Macau)

19 Restricting Venue Entry to Higher Socioeconomic Groups e.g. dress codes (Europe); income test (Panama, Singapore, Germany); significant entrance fees (Papua New Guinea, Singapore) Effectiveness unknown, although low income is a good predictor of PG status in western countries

20 POLICY INITIATIVES Restrictions on How Gambling is Provided

21 Modifying EGM Parameters Speed; Near misses; # play lines; Bill acceptors; Bet size; Maximum win; Interactive features; Pop-up messages; Clock; Mandatory cash out; Payback %; Privacy; $ versus credits; Lights & Sounds; Seating Research shows some utility for: eliminating early big win, reducing near misses, slower speed, dynamic pop-up messages, lower max bet size, fewer betting lines, eliminating bill acceptors However, magnitude of effect is small, especially for PGs Reminiscent of attempts to minimize tobacco harm by adding filters and use of low tar cigarettes (i.e., these will always be high risk devices)

22 Player Pre-Commitment Some EGMs and Internet gambling sites allow gamblers to establish time and/or spending limits. Low utilization when pre-commitment not mandatory Even when mandatory Limited effectiveness when limits easily revocable Limited effectiveness if other opportunities available (i.e., ability to use other EGMs or other Internet sites that do not require precommitment) Limited effectiveness if you can use other people s ID

23 Elimination of Player Reward/Loyalty Programs Heavy gamblers are most likely to have these Anecdotally, appears to encourage excessive expenditure Unclear why these exist at all Most countries do not allow incentivization of increased alcohol, tobacco, or prescription drug use consumption Reward responsible gambling

24 Operator Imposed Maximum Loss Limits Exists on some govt-operated online sites; NZ lottery; and in Norway (EGMs, sports betting, & online site) In Norway, implementation associated with: Lower gambling revenue (especially toward end of month) Dramatically lower help-line calls for slot machines (n = 42 from ) No overall decrease in PG, which was quite low to begin with (~1.0%)

25 Employee PG Awareness Training Began in Holland in late 80s, now common The few satisfaction or knowledge evaluations have been positive However, in alcohol field, training of alcohol servers has had mixed behavioural effects due to conflict with profits, lack of enforcement, and personal drinking habits which are inconsistent with the policy

26 Automated Intervention for At-Risk Gamblers High level of casino visitation leads to automatic intervention in Netherlands and Austria Risky gambling patterns in Player Card data used to alert staff (Saskatchewan; SkyCity casino NZ) or player (Sweden) Positive behavioural results, more so for direct player alerts Theoretically sensible, as much easier to treat emerging rather than existing problems

27 Restricting Access to Money House credit banned throughout Europe, Australia, Canada (except ONT); U.S. only country where common ATMs typically permitted at gambling venues (not South Africa, Singapore); withdrawal limits in some places Theoretically sensible, as ATM use much higher for PGs, and PGs often report that restricting ATM availability would be very helpful Only one empirical study in Australia, which showed clear beneficial behavioral effects

28 Restrictions on Concurrent use of Alcohol & Tobacco Free and/or low cost alcohol common in U.S., eastern Europe, some Australian states, Macau Smoking now only common in Aboriginal casinos and some non-western countries Very strong association with PG, thus, restrictions may serve strong preventative measure Evidence indirectly seen in significant reduction in gambling revenue occurring in jurisdictions that instituted smoking bans Puzzle concerns mechanism by which this revenue has recovered

29 Restricting Advertising Most European countries limit publicity and require informing public about dangers. Increasingly common in other countries. Small to negligible impact on most people, with two important exceptions: PGs report that advertising is a common trigger to gamble In the field of alcohol and tobacco, advertising is known to promote youth involvement

30 Gambling Venue Design Vegas-style design believed to encourage gambling both by venue developers and by gamblers However, very little evidence on whether it impacts actual gambling behaviour Unlikely to be strong effect, as EGM revenue per machine similar regardless of location (convenience stores, casinos, restaurants, bars, hotels, ships)

31 Increasing Cost of Gambling Effective policy for reducing harm associated with alcohol & tobacco Does this apply to gambling when highest patronization occurs for forms with lowest payback % (i.e., lotteries, instant win tickets)? For gambling, perception of cost more important than actual cost (i.e., people attentive to cost of playing relative to possible reward) preference for penny slots, cheap lottery tickets & large jackpots Thus, probably utility in legislating a minimum bet size and maximum win size

32 Government vs. Private Provision Conflict of interest exists when provider and regulator part of same organization (government) Theoretically, this conflict more likely to impede implementation of policies that interfere with revenue. However, in practice, responsible gambling measures more common in jurisdictions with this conflict (e.g., Canada vs U.S.). Furthermore, in alcohol field, monopolistic &/or govt provision is associated with less harm to public

33 SUMMARY Large array of initiatives exist, most with relatively little direct empirical evidence about effectiveness. However: Someevidence on most of these initiatives Vast literature in other prevention fields to guide PG efforts

34 SUMMARY Most commonly implemented measures tend to be least effective ones (e.g., awareness campaigns, employee training, EGM modifications) Furthermore, when potentially more effective measures are implemented (e.g., reduced EGMs, reduced hours), reductions usually too minor to have major effect Unrealistic desire to implement effective prevention policies that do not inconvenience non-problem gamblers or reduce revenues

35 BEST PRACTICE #1: Recognize that Effective PG Prevention will Likely Require Some Inconvenience to Nonproblem Gamblers and Some Loss of Revenue Goal of harm minimization has to be given equal priority to revenue generation

36 BEST PRACTICE #2: Use a Large Array of Educational and Policy Initiatives Almost nothing that is not helpful to some extent. Conversely, no single measure has great ability to prevent problems. Recognize that policy measures are equally, if not more important than educational initiatives

37 BEST PRACTICE #3: Coordinate these Multiple Initiatives Offer these initiatives simultaneously, rather than sequentially, and make sure the messages do not conflict. A shotgun blast only effective if every pellet directed at same target at the same time. Each overlapping initiative reinforces the others, creating a synergy beyond what occurs with individual efforts.

38 BEST PRACTICE #4: Decrease the General Availability of Gambling Limit or reduce the number of Casinos/EGM venues. Limit number of gambling formats. Keep gambling venues away from vulnerable populations. Restrict gambling opportunities to dedicated gambling venues. Reduce hours of operation.

39 BEST PRACTICE #5: Eliminate or Constrain High-Risk Forms of Gambling i.e., EGMs, Casino Table Games, Internet Gambling Constrain EGM speed, min & max bet, max win size, near misses, # play lines Require pre-commitment

40 BEST PRACTICE #6: Eliminate Reward Cards or Use them to Foster Responsible Gambling No reward points after certain level of expenditure Use the data to proactively alert players to risky behaviour

41 BEST PRACTICE #7: Restrict who is Eligible to Gamble Introduce graduated ability to gamble independently. Raise legal age.

42 BEST PRACTICE #8: Restrict the Use of Tobacco and Alcohol While Gambling Deters PGs from gambling in the first place. Encourages them to take breaks. Allows them to gamble without disinhibiting effects of alcohol.

43 BEST PRACTICE #9: Restrict Access to Money While Gambling Gambling venues should not offer credit. ATMs should not be conveniently close.

44 BEST PRACTICE #10: Impart Knowledge, Attitudes, and Skills to Inhibit the Progression to Problem Gambling Best done with comprehensive school-based programs (e.g., Stacked Deck). However, adult interventions also necessary (RGICs; Information/Awareness Campaigns; Low Risk Guidelines; etc.)

45 BEST PRACTICE #12: Keep these Initiatives in Place for Many Years, Because Population-Wide Behavioural Change Takes a Long Time

46 For more information Williams, R.J., West, B., and Simpson, R. (2012). Prevention of Problem Gambling: A Comprehensive Review of the Evidence and Identified Best Practices. Report prepared for the Ontario Problem Gambling Research Centre and the Ontario Ministry of Health and Long Term Care. Oct 1,