From Disabling to Enabling the Public Interest: Natural Transitions From Gambling Exposure to Adaptation and Self‐regulation

Orford's article [1] is an important and interesting review of gambling and the public interest. It raises many questions worthy of discussion and debate. It also reveals the complexity associated with managing gambling and gambling related problems. Orford successfully identifies the primary issues that are central to a thoughtful discussion about gambling, public policy and the relationship of these matters to the health of the public. Since David Korn and I first suggested that gambling could be treated as a public health matter, and provided a framework for doing this, the association between gambling and public health has flourished around the world [2, 3]. Nevertheless, the evidence about gambling-related harms is nascent and can be interpreted from multiple perspectives. Consequently, observers can have difficulty distinguishing scientific evidence from conventional wisdom. The following discussion examines the conventional wisdom that Orford tacitly presents in his article: that is, objects of addiction (e.g. gambling, alcohol, etc.) can overpower the human will and, as a result, compromise people's capacity to live harmoniously with activities or objects that hold addiction potential. Orford's article also implies that 1) the risks of engaging with unregulated gambling are unacceptable, and 2) there is little or no benefit to use potential objects of addiction such as gambling. Despite the potential dangers associated with activities that rest upon variable ratio reinforcement schedules, and similar to drinking beverage alcohol and engaging in sexual intercourse, gambling likely has some worthwhile benefits [e.g. 2-5]. For example, drinking small amounts of alcohol on a regular basis is now recognized as having health benefits; similarly, having sex is healthy for the cardiovascular system as well as the spirit. In excess, however, these behaviors can have serious adverse health consequences. Hormesis exists when exposure to high doses of an object results in toxicity and exposure to low doses of the same object has important health benefits [e.g. 6, 7]. Gambling, like drinking alcohol, displays a ‘dose–response’ association that reflects hormesis as an underlying process. This fascinating dose–response relationship often encourages government intervention to protect the public from toxic health effects—that is, too much (high dose) of a good thing (low dose). When, where and how much the government gets involved to minimize the risks and maximize the benefits of gambling has been the focus of regulatory debate since the rule of law was first established. In civilized cultures, stronger groups care for the weak and vulnerable—how much protection and care is required remains a topic of considerable debate for both public policy makers and public health workers alike. As a means of advancing the greater good, it is the responsibility of the government to protect and serve the public. In free societies, people have the liberty to engage in activities that are not in their best interest despite warnings and protestations from those who either ‘know better’ or think they know better. Education and information serve to encourage people to make better choices for themselves. Historically, governments have struggled with public policy issues about various forms of consumption: how much should people drink, drug or gamble, for instance. When people are intemperate, whether it is gambling, drinking or engaging in sexual intercourse, observers have often viewed these excessive patterns as a reflection of poor personal choices or values. With advances in neurobiological and neurogenetic research, this view has gradually evolved into a more complex understanding that is informed by the interaction between personal vulnerabilities and a risk matrix of social setting exposure [e.g. 8]. In the area of gambling studies, this transition to a more complex and interactive model reflects the move away from an individual psychology of addiction to a population-based psychology that includes consideration of the public health, behavioral economics, socio-cultural influences and other new expressions of what had been a small group oriented social psychology. My colleagues and I have been developing public health research tools to permit a systematic examination of exposure to gambling and its effects on various jurisdictions and population segments [9]. If, as the implicit conventional wisdom suggests, exposure to gambling is inherently toxic, then more exposure, like radiation for example, should lead inevitably to increasing levels of morbidity and perhaps even mortality. In recently legalized gambling settings, such as Iowa and Missouri, new gambling exposure has led to increases in the numbers of helpline calls and increases in the requests for exclusion from casinos [10, 11]. However, in more mature gambling settings (e.g. Nevada), exposure seems to have less adverse effect [9]. This evidence reveals a level of phenomenological complexity that scientists and policy makers rarely consider. Without a multidimensional and interactive consideration, clinicians, scientists and public policy makers alike will find it difficult to determine what events gambling can ‘cause’ (e.g., suicide, bankruptcy, or improved health) as either 1) a necessary and sufficient cause, or 2) a partial cause. In turn, this confusion will make it difficult to distinguish gambling ‘facts’ from gambling ‘fictions’. Deregulation of gambling certainly will lead to increased levels of exposure – though the UK is already among the most exposed gambling societies on earth. In the USA, there are venues with extraordinarily high and longstanding levels of gambling exposure (e.g. Nevada). If the exposure hypothesis is accurate, then it is reasonable to suppose that Nevada has proportionately more gambling related problems than other less exposed venues. However, the extant evidence does not support this expectation. Despite being about eight times more exposed to gambling than the next most exposed state (i.e. New Jersey), which is considerably more exposed than all of the other states, Nevada does not show proportionately more gambling related problems than the other states [9]. On some indicators, Nevada has fewer gambling-related problems than less exposed states [12]; Nevada has the lowest rates of youth gambling in the USA reported to date [12]. Further, Nevada's youth do not gamble in casinos more than their counterparts from states with far less access to casinos [12]. Observations about gambling-related problems in Nevada provide support for the adaptation hypothesis of addiction. That is, after the novelty of initial exposure, people gradually adapt to the risks and hazards associated with potential objects of addiction. Similarly, adaptations have occurred with alcohol in general and gin in particular, for example [13]. Consequently, the public policy questions of importance are, how long does it take to adapt and can we afford to wait that long after a group is newly exposed? In the UK, few people are newly exposed to gambling. Gambling-related regulation has been integrated into the UK culture and its public policies for more than seven centuries [14]. Current plans to deregulate UK gambling mean that people will be exposed to more and different strains of gambling than the ones that they already have adapted to. Whether the people of the UK have sufficient immunity from their centuries of gambling experience and adaptations to manage new forms of gambling without additional adversity remains to be determined; but it is likely that some immunity exists. The presence of this immunity suggests that time will reveal whether the dire claims of dramatically increasing gambling related morbidity are hyperbolic. An old proverb reminds us that ‘Truth is the daughter of time’[15]. Deregulation permits increased access to objects of temptation. Like exposure, in the short term, temptation tends to stimulate more social adversities. However, temptation has worth. The value of tempting activities (e.g. gambling, investing, engaging in sex) is that enticements provide the opportunity to learn self-control and build character. Self-regulation emerges from the gentle interplay with temptation; absent such access, it is more difficult if not impossible for people to learn how to regulate themselves. When people lack self-regulation, governments have little choice but to exert greater control. At one extreme, government regulation can establish an Orwellian state without personal liberty [16]; anarchy resides at the other extreme. For societies of every stripe, the question of considerable difficulty is how much government regulation is optimal to arouse the self-regulation necessary to sustain a civilized society. Orford makes the common mistake of stereotyping the various purveyors of gambling as a monolithic ‘industry’—as if all suppliers spoke with one voice. Interestingly, an epidemiology of the gambling industry reveals that this ‘industry’, like the general population, is comprised of many different segments. These subunits represent groups with distinct attributes. Some industry segments are interested in the public health and welfare; others are not. Gambling regulations are similar: an epidemiological review of US gambling regulations reveals that these are heterogeneous with respect to objectives across the states [17]. Viewing these various gambling or regulatory segments as homogenous leads to the very same errors that people make when they consider the distribution and determinants of an illness as uniform across the general population. Orford was part of a team that, in my opinion, conducted the finest national study of gambling and its social impacts to date [18]. Along with other national studies, this contribution reveals that the rate of the most serious form of gambling disorder has been surprisingly stable across national boundaries, research methods and shifting exposure levels [19]. Despite the capacity of humans to adapt to the presence of tempting objects and the adverse consequences associated with exposure to these objects, we need to be concerned with gambling related problems because these difficulties can compromise the public health and welfare. We must also carefully manage the delicate balance between liberty and regulation. Liberty, temptation, opportunity and regulation commingle to influence health in complex and unexpected ways. When infirmities emerge, these complex interactions defy simple regulatory solutions. In the absence of legal gambling, there are gambling problems. In the presence of unlimited legalized gambling, problems are less than expected. Norman Zinberg (personal communication) noted long ago that bad laws prevent few and punish many; good laws prevent many and punish few. The challenge facing public policy makers is to employ gambling regulations that strike the right balance between prevention and punishment. The author extends special thanks to Sarah Nelson, Christine Reilly, Chrissy Thurmond, Debi LaPlante and Richard LaBrie for their important contributions to this article. This work was supported in part by funding from the National Center for Responsible Gaming, the Iowa Department of Public Health, the Greater Kansas City Community Foundation and the Port Authority Problem Gambling Fund, and a grant from the National Institute on Alcohol Abuse and Alcoholism (R01-AA014710–01A1).