Christiane Poulin

Harm Reduction: Concepts and Practice. A Policy Discussion Paper

This paper provides an overview of the context, definition, and key features of the harm reduction approach, and provides several examples of current programs in various countries. Both licit and illicit drugs are included in these illustrations. Some of the critical issues, and the strategies needed to advance harm reduction, are discussed. [Translations are provided in the International Abstracts Section of this issue.]

Problem Gambling Among Adolescent Students in the Atlantic Provinces of Canada

The objectives of the present study were to determine the prevalence of problem gambling among adolescent students in the Atlantic provinces of Canada, and to determine the role of age and deception about legal age status as potential risk factors for problem gambling. In 1998, a total of 13,549 students in grades 7, 9, 10 and 12 in the public school systems of the four Atlantic provinces completed a self-reported anonymous questionnaire that included the South Oaks Gambling Screen-Revised for Adolescents. About 8.2% and 6.4% of adolescent students met the broad definition of at-risk and problem gambling, respectively. About 3.8% and 2.2% of adolescent students met the narrow definition of at-risk and problem gambling, respectively. The prevalence of problem gambling did not vary according to age. Using a fake identification or lying about ones age was found to be an independent risk factor for problem gambling. Playing video gambling machines was the gambling activity associated with the single greatest independent risk of using a fake identification or lying about ones age. It was concluded that deception about legal age status may be a facilitating factor permitting adolescents to gamble to the point of experiencing problems.

An assessment of the validity and reliability of the SOGS-RA.

The present is a validation study seeking to determine the degree of confidence that can be placed on inferences about problem gambling among adolescents in the Atlantic provinces, based on their South Oaks Gambling Screen-Revised for Adolescents (SOGS-RA) scores. The major source of data was a 1998 survey of 13,549 students in junior and high school of the public school systems of the 4 Atlantic provinces of Canada. The SOGS-RA was found to have adequate stability and internal consistency reliability. Statistically significant gender differences were demonstrated relative to endorsement and construct validity. Regarding the latter, this study shows that the existing cut-point of the SOGS-RA score for problem gambling identifies as problem gamblers, markedly different proportions of male than female daily gamblers. Regarding construct validity in relation to the Atlantic Alcohol and Drug Risk Continua, this study suggests that while statistically highly significant, the association between problem gambling and substance-related problems may be of low clinical significance. Regarding criterion validity, there is an urgent need to perform the types of enquiry that will allow clarification about how adolescent problem gambling is conceptualized, by adults versus adolescents, by males versus females, and from a clinical versus a public or population health perspective.

Concordance between the SOGS-RA and the DSM-IV criteria for pathological gambling among youth.

This study assessed the possible differences in the classification of adolescent gamblers when using the South Oaks Gambling Screen-Revised for Adolescents (SOGS-RA; K. C. Winters, R. D. Stinchfield, & J. Fulkerson, 1993) versus a clinical interview that was based on Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) criteria for pathological gambling. A total of 631 adolescents ages 15-17 years participated in the two phases of the study. Results revealed that of the 93 adolescents who had been screened as problem gamblers according to the SOGS-RA, only 7 could be clinically confirmed as pathological gamblers according to the criteria used at present to define pathological gambling. The need to clarify the construct of pathological gambling among youth is discussed.

School smoking bans: do they help/do they harm?

INTRODUCTION AND AIMS The international evidence about the effectiveness of school smoking bans on youth smoking initiation is equivocal. The purpose of the present study was to examine the association between school smoking bans and smoking initiation as a health outcome as well as academic achievement as an educational outcome, taking into account socio-economic status. DESIGN AND METHODS This multi-level study was based on a cross-sectional self-reported anonymous data from 12,990 students who participated in the 2002 Student Drug Use Survey in the Atlantic Provinces. The main outcomes were having smoked a first whole cigarette in the year prior to the survey, and academic performance. The main independent variable at the individual- and school-levels was a school rule against smoking on school property or at school events, as reported by students. RESULTS Smoking initiation was predicted by individual-level demographic factors and by the contextual factor of attending a school with a high prevalence of established smoking, but failed to be predicted by a school smoking ban. The academic performance of students who indicated there was no school smoking ban was found to worsen as an increasing proportion of the student body indicated that such a rule existed. Lower socio-economic status was found to be an independent predictor of smoking initiation and poorer academic performance. DISCUSSION AND CONCLUSIONS A school ban against smoking, in addition to not being clearly effective, might also not be entirely benign. School smoking policy should be monitored as to educational outcomes and the impact of policy on groups vulnerable to smoking.

Public Health: Gambling

gambling is that it is a behaviour in which people have indulged for millenia, that there are both potential benefits and harms to individuals and communities arising from gambling activities and that the general stance toward gambling should be one of harm reduction. This perspective is articulated, for example, in a position paper published in 2000 by the Canadian Public Health Association (CPHA) in response to the recognition of the expansion of gambling in Canada as an emerging public health issue. So now let’s talk about the elephants in the room. The first elephant is the inequitable distribution of the risks and benefits of gambling in our society. In theory, government gambling revenues benefit all of society. In reality, since gambling revenues go into general revenue pots, individuals who do not participate in gambling activities end up being the biggest winners because they benefit without having invested anything. Furthermore, a disproportionate number of individuals who participate in certain gambling activities (e.g., video lottery terminals [VLTs]) are from disadvantaged groups in our society. Decisions and policy pertaining to gambling need to be based on a full accounting of the health, economic and social benefits and costs of gambling, rather than on only the short-term benefits of employment and tax revenue. The second elephant in the room is that treatment of problem gambling cannot undo the damage caused by lost wealth. Based on the Canadian Problem Gambling Index, administered to respondents of the Canadian Community Health Survey, an estimated 2% of Canadians 15 years of age and older are considered to have gambling problems. Treatment is based on best practices in managing addictions. However, little is known about the actual effectiveness of various treatment methods and programs. Nevertheless, although treatment may stop the hemorrhaging of an individual’s wealth, it cannot restore lost wealth, and lost wealth can have an impact on health for decades and even generations. The third elephant has to do with health promotion. It is time for governments and public health advocates to stop being seduced by the promise of anti-gambling campaigns and education that place the onus of self-control on the shoulders of the very individuals who have a serious disorder of impulse control. Rather, we should apply what has been learned from tobacco control strategies — success is achieved primarily through public policy. The causal link between problem gambling and the expansion of government-sanctioned gambling opportunities has not been clearly demonstrated. However, a recent natural experiment in Nova Scotia has provided crucial evidence that public policy acting to decrease the availability of gambling opportunities can be effective in stemming problem gambling. In November 2005, the provincial government removed 1000 VLTs from licensed premises, lowering the number of VLTs previously available in Nova Scotia by 30%. This action, combined with a midnight shutdown and the removal of the “stop” button on VLTs (the button fooled gamblers into thinking that they had control over the machine), resulted in a decrease in VLT gambling activities and VLTrelated problem gambling. Furthermore, although the total annual amount wagered on VLTs in Nova Scotia had increased in previous years, it decreased by 8.4% from the 2004/05 to the 2005/06 fiscal year, from

The association between substance use, unplanned sexual intercourse and other sexual behaviours among adolescent students.

895.1 million to

Gender differences in the association between substance use and elevated depressive symptoms in a general adolescent population.

820 million respectively. The cost to the provincial government was a decrease of 11.4% in VLT revenues, from

Medical and nonmedical stimulant use among adolescents: from sanctioned to unsanctioned use

132.6 million to

From attention-deficit/hyperactivity disorder to medical stimulant use to the diversion of prescribed stimulants to non-medical stimulant use: connecting the dots

117.4 million. Given how difficult it is to effect behavioural change at the individual and population levels, the changes to the VLT program can be judged to have been cost-effective, particularly since the government did not have to implement an ongoing program to achieve this result. Our governments currently have at their disposal the means of creating strong public health tools to control the expansion of gambling and decrease problem gambling in Canada. Applying what has been learned from tobacco control strategies, we could evaluate and implement the following measures: • Decrease the number of licensed ticket lotteries, including charitable lotteries, and increase prices through taxation. • Ban the advertising of gambling activities. • Require retailers to place lottery tickets behind the counter, out of sight. • Require the adoption of plain packaging of gambling products, with a warning label that the gambling product may be addictive.