The world of gambling: the National Gambling Experiences series

Addiction has published descriptions of the experiences with gambling in 19 countries world-wide. Most commonly countries have alternated between periods of restriction or prohibition and periods of liberalization and expansion. A large expansion in the late 1980s in many jurisdictions has led to increased focus on the associated harms, addiction, harm minimization and treatment. Approximately 4 years ago Addiction launched a series on National Gambling Experiences, in which authors provided a description and commentary on the development and effect of gambling in their country. The purpose of the series was to stimulate further understanding and research on the topic 1. At that time, Addiction was one of a limited number of journals in the addiction and substance abuse area that accepted gambling-focused research papers. Since its inception as the British Journal of Addiction in 1981, papers on gambling addiction appeared periodically. More recently, the number of published papers in Addiction has ballooned, with more than 60 published or in press since the launch of this series. Interest in this area more generally has also expanded dramatically 2. The strength of the evidence for an addiction conceptualization of gambling problems influenced decisions concerning the DSM-5, in which the diagnosis of pathological gambling (included in the DSM since 1980) was renamed gambling disorder and was moved to a new ‘Addictions and Related Disorders’ section of the manual 3. Inclusion of gambling disorder as the sole representative of non-substance addiction both recognizes its status as the most well-understood behavioral addiction 4. The international coverage of this series was broad, and included submissions from Autralasia (Australia 5, New Zealand 6), South America (Brazil 7), North America (Canada 8, United States 9), Europe (Finland 10, Sweden 11, Norway 12, France 13, Switzerland 14 , Czech Republic 15, Spain 16, the Netherlands 17, Germany 18, United Kingdom 19) and Asia (Taiwan 20, China 21, Singapore 22, India 23 ). The selection of countries profiled was, of course, not random, so countries with relatively more gambling academic involvement are undoubtedly over-represented. Contributors were asked to describe the trajectory of gambling availability and its recognition as a potential problem, the evolution of policy and regulation, treatment availability and the research base. Many of the papers made reference to the deep historical roots of gambling in their jurisdictions (e.g. tracing gambling back to the 6th century bce). Frequently, the time-line included periods of prohibition or extensive restriction of gambling followed by liberalization. As with substances, illegal forms of gambling predominate during periods of restriction. The addictive properties of gambling have been recognized as early as the late 19th century when gambling was seen, along with alcohol, cocaine and morphine, as one of the four major addictions in Germany 18. A common experience world-wide was a large expansion of commercial gambling in the 1990s, often in response to a desire for increased government revenues. These shifts to liberalization, which continue, involved a ‘quiet relaxation of regulation’ 8 in some jurisdictions (e.g. Brazil, Canada, Australia, United States), and in others a more dramatic change has taken place (post-communist expansion in the Czech Republic and post-Franco era in Spain). Government monopolies on commercial gambling currently exist in the Netherlands, Norway, Finland, Canada, Singapore and Germany. In other countries, governments regulate and tax commercial gambling and attempt to control illegal forms of gambling. Expansion of commercial gambling is sometimes broad-based, but most often is specific to some gambling formats such as lottery, casino games or electronic gambling machines (EGMs), which includes slot machines and video lottery terminals. In many jurisdictions, separate regulations exist for lottery versus other forms of gambling such as EGMs and casino table games. This distinction parallels general recognition that the latter can cause relatively more social and individual harm. Internet gambling is the latest regulatory challenge, as noted by the papers published in the series most recently 12-15. Internet gambling involvement is growing, although it still represents a minority of the commercial market in most jurisdictions. Heavy and problem gamblers are particularly likely to report gambling on-line 13, 24, 25. The shift from prohibition to liberalization provides the opportunity to gauge the impact of legalized gambling opportunities. Norway is a particularly informative experience, in that gambling has been restricted and liberalized a number of times in recent history, including a shift from a very high density of EGMs in the 1990s to a complete EGM ban from 2007 to 2009, and restrictions on accessibility and design (e.g. restricted hours, EGM features) since 2009. Data presented by Rossow & Hansen 12 reveal decreased gambling participation, decreased calls to the gambling helpline and decreased treatment participation post-restriction, but also evidence of a small substitution effect (increased helpline calls for problems with other types of gambling). Documentation of these impacts is an important contribution to the field. These policy-impact analyses are facilitated by good surveillance data. Prevalence surveys of gambling participation and harms are available in at least 16 of the 19 counties. Prevalence rates of harm (e.g. problem gambling) across jurisdictions are difficult to compare due to variation in methodologies, but an effort by Williams and colleagues 26 to standardize statistically the estimates concluded that the lowest rates of gambling problems tend to occur in Europe, with intermediate rates in North America and Australia and the highest rates in Asia. One interesting observation in jurisdictions that have had repeated cross sectional surveys is that problem gambling rates are either stable or dropping despite increased availability in amounts or types of gambling. This effect has been labelled as an ‘adaptation effect, a population adjustment to a relatively mature gambling market’ 27, 28. Binde, in describing the Swedish experience, expands this concept by proposing that the apparent stability of problem gambling rates reflects a ‘homeostatic system’, involving the gambling market, regulation, prevention and treatment as well as individual adaption 11. However, it is also important to note that the time-frames of changes in legalization and access to various formats of gambling and the assessments of prevalence rates are also relatively short in duration. Thus, longer-term evaluations of sustained changes in gambling legalization and access are not available. The government regulatory response to problem gambling, of course, varies significantly across jurisdictions. An early contribution to this series by Adams & Rossen 6 describes New Zealand's public health model, a relatively coordinated government response aimed at minimizing the negative impacts on individual and communities (which the authors describe as having a disappointing effect). In contrast, in countries such as India and Taiwan, gambling-related harms are essentially unacknowledged. Authors from Asian countries (Singapore, Taiwan, China) describe a positive cultural role of gambling. In Singapore, for example, small wager gambling is seen as an important social activity. Chinese cultures see games such as Mahjong as cultural assets and an important part of celebrations and festivals 20, 21. Provision of treatment for gambling problems is similarly variable, and also differs in terms of whether it is provided in the addiction-treatment sector (most places), the mental health sector (e.g. United Kingdom) or as a free-standing system (e.g. New Zealand, United States). Gamblers Anonymous is available to some degree in at least 10 regions, in particular in the United States. One very common source of support across countries is the problem gambling helpline. Helpline intervention models differ in terms of whether they focus on treatment referral or whether they provide brief treatment interventions. Prevalence surveys have underscored the low rates of treatment-seeking among individuals who screen positively for gambling problems, with estimates hovering around 10% 29. A number of jurisdictions provide on-line intervention as one way of increasing treatment uptake (Switzerland, Norway, Finland, Singapore). The promotion of natural recovery with brief interventions has been a popular area of focus in the problem gambling literature (see 30 for review). Another common focus in numerous countries is harm reduction, characterized as the promotion of ‘responsible gambling’. A small number of jurisdictions have regulated restricted hours of operation for commercial gambling, and a variety of EMG harm reduction features such as restrictions on bill acceptors and wager sizes and pop-up reminders to limit spending (e.g. Norway, Sweden, Canada). Whether these features lead to significant reductions in harm is essentially unknown. Programs, referred to as self-exclusion programs, that allow individuals to ban themselves from casinos and other gambling venues, are very common and mentioned in at least six geographically diverse jurisdictions. A number of uncontrolled trials have found that individuals who participate tend to have significant gambling problems and that participation is linked with reduced gambling involvement, at least during the period of the ban, but randomized trials are non-existent. 31 Research on gambling and its impacts has increased significantly, although most authors lamented the limited availability of funds. The collaboration of industry, government and other stakeholders with academic researchers is a contentious issue 32-34, which has similarities to earlier debates in the alcohol and tobacco fields. In jurisdictions where gambling specific funding is available (Australia, Canada, New Zealand, United States), this is often through government or industry-funded mechanisms of varying degrees of independence. Best practices for handling these dilemmas are evolving 35. Unfortunately, gambling disorder remains unconnected to any institutes’ priorities in the US National Institutes of Health, which provides more than 90% of funding for research related to substance use disorders world-wide. These papers, as a set, are informative and thought-provoking in many more ways than we have noted. Hopefully, they will spur additional research and policy efforts to understand gambling more clearly and prevent and treat gambling disorder. Although you may have reviewed the individual contributions as they were published over the last 4 years, we encourage you to re-consider them as a collection. They are now available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1360-0443/homepage/national_gambling_experiences.htm. D.C.H. received salary support from the Alberta Gambling Research Institute.