Howard J. Shaffer

Estimating the prevalence of disordered gambling behavior in the United States and Canada : A research synthesis

OBJECTIVES This study developed prevalence estimates of gambling-related disorders in the United States and Canada, identified differences in prevalence among population segments, and identified changes in prevalence over the past 20 years. METHODS A meta-analytic strategy was employed to synthesize estimates from 119 prevalence studies. This method produced more reliable prevalence rates than were available from any single study. RESULTS Prevalence estimates among samples of adolescents were significantly higher than estimates among samples of adults for both clinical (level 3) and subclinical (level 2) measures of disordered gambling within both lifetime and past-year time frames (e.g., 3.9% vs 1.6% for lifetime estimates of level 3 gambling). Among adults, prevalence estimates of disordered gambling have increased significantly during the past 20 years. CONCLUSIONS Membership in youth, treatment, or prison population segments is significantly associated with experiencing gambling-related disorders. Understanding subclinical gamblers provides a meaningful opportunity to lower the public health burden associated with gambling disorders. Further research is necessary to determine whether the prevalence of disordered gambling will continue to increase among the general adult population and how prevalence among adolescents will change as this cohort ages.

DSM-IV pathological gambling in the National Comorbidity Survey Replication

BACKGROUND Little is known about the prevalence or correlates of DSM-IV pathological gambling (PG). METHOD Data from the US National Comorbidity Survey Replication (NCS-R), a nationally representative US household survey, were used to assess lifetime gambling symptoms and PG along with other DSM-IV disorders. Age of onset (AOO) of each lifetime disorder was assessed retrospectively. AOO reports were used to study associations between temporally primary disorders and the subsequent risk of secondary disorders. RESULTS Most respondents (78.4%) reported lifetime gambling. Lifetime problem gambling (at least one Criterion A symptom of PG) (2.3%) and PG (0.6%) were much less common. PG was significantly associated with being young, male, and Non-Hispanic Black. People with PG reported first gambling significantly earlier than non-problem gamblers (mean age 16.7 v. 23.9 years, z=12.7, p<0.001), with gambling problems typically beginning during the mid-20s and persisting for an average of 9.4 years. During this time the largest annual gambling losses averaged US

Gambling and the Health of the Public: Adopting a Public Health Perspective

4800. Onset and persistence of PG were predicted by a variety of prior DSM-IV anxiety, mood, impulse-control and substance use disorders. PG also predicted the subsequent onset of generalized anxiety disorder, post-traumatic stress disorder (PTSD) and substance dependence. Although none of the NCS-R respondents with PG ever received treatment for gambling problems, 49.0% were treated at some time for other mental disorders. CONCLUSIONS DSM-IV PG is a comparatively rare, seriously impairing, and undertreated disorder whose symptoms typically start during early adulthood and is frequently secondary to other mental or substance disorders that are associated with both PG onset and persistence.

Estimating the Prevalence of Adolescent Gambling Disorders: A Quantitative Synthesis and Guide Toward Standard Gambling Nomenclature

During the last decade there has been an unprecedented expansion of legalized gambling throughout North America. Three primary forces appear to be motivating this growth: (1) the desire of governments to identify new sources of revenue without invoking new or higher taxes; (2) tourism entrepreneurs developing new destinations for entertainment and leisure; and (3) the rise of new technologies and forms of gambling (e.g., video lottery terminals, powerball mega-lotteries, and computer offshore gambling). Associated with this phenomenon, there has been an increase in the prevalence of problem and pathological gambling among the general adult population, as well as a sustained high level of gambling-related problems among youth. To date there has been little dialogue within the public health sector in particular, or among health care practitioners in general, about the potential health impact of gambling or gambling-related problems. This article encourages the adoption of a public health perspective towards gambling. More specifically, this discussion has four primary objectives:1. Create awareness among health professionals about gambling, its rapid expansion and its relationship with the health care system;2. Place gambling within a public health framework by examining it from several perspectives, including population health, human ecology and addictive behaviors;3. Outline the major public health issues about how gambling can affect individuals, families and communities;4. Propose an agenda for strengthening policy, prevention and treatment practices through greater public health involvement, using the framework of The Ottawa Charter for Health Promotion as a guide.By understanding gambling and its potential impacts on the publics health, policy makers and health practitioners can minimize gamblings negative impacts and appreciate its potential benefits.

Toward a Syndrome Model of Addiction: Multiple Expressions, Common Etiology

This article reviews the extant published and unpublished studies that estimate the prevalence of adolescent gambling problems in North America. The nine nonduplicative studies identified by our literature search included data collected from more than 7700 adolescents from five different regions of the United States and Canada. In addition to comparing the conceptual and methodological differences that exist among these studies, this article employed a meta-analytic strategy to synthesize prevalence estimates from the existing studies. This analysis revealed that within a 95 percent confidence interval, between 9.9% and 14.2% of adolescents are at risk of developing or returning to serious gambling problems. Similarly, between 4.4% and 7.4% of adolescents exhibit seriously adverse compulsive or pathological patterns of gambling activity. Finally, the discussion proposes a generic multi-level classification scheme to reconcile the divergent classification methods and data reporting strategies. This new multi-level approach to reporting gambling prevalence will facilitate interstudy comparisons among existing estimates of gambling prevalence and help to provide a general data reporting system for future research.

A Science-Based Framework for Responsible Gambling: The Reno Model

It is common for clinicians, researchers, and public policymakers to describe certain drugs or objects (e.g., games of chance) as “addictive,” tacitly implying that the cause of addiction resides in the properties of drugs or other objects. Conventional wisdom encourages this view by treating different excessive behaviors, such as alcohol dependence and pathological gambling, as distinct disorders. Evidence supporting a broader conceptualization of addiction is emerging. For example, neurobiological research suggests that addictive disorders might not be independent:2 each outwardly unique addiction disorder might be a distinctive expression of the same underlying addiction syndrome. Recent research pertaining to excessive eating, gambling, sexual behaviors, and shopping also suggests that the existing focus on addictive substances does not adequately capture the origin, nature, and processes of addiction. The current view of separate addictions is similar to the view espoused during the early days of AIDS diagnosis, when rare diseases were not

Pathological gambling among adolescents: Massachusetts Gambling Screen (MAGS).

As social observers increasingly identify gambling-related problems as a public health issue, key stakeholders need to join together to reduce both the incidence and prevalence of gambling-related harm in the community. This position paper describes a strategic framework that sets out principles to guide industry operators, health service and other welfare providers, interested community groups, consumers and governments and their related agencies in the adoption and implementation of responsible gambling and harm minimization initiatives.

The Road Less Travelled: Moving From Distribution to Determinants in the Study of Gambling Epidemiology

This article describes the development of the Massachusetts Gambling Screen (MAGS). The purpose of the MAGS is to provide a brief clinical screening instrument that can (1) yield an index of non-pathological and pathological gambling during a 5 to 10 minute survey or interview and (2) document the first psychometric translation of the proposed DSM-IV pathological gambling criteria into a set of survey or clinical interview questions. The development data for this instrument were obtained from a survey of 856 adolescents who were students in suburban Boston high schools. The results provided evidence that weighted item scores (i.e., discriminant function coefficients) could correctly classify 96% of adolescent gamblers as pathological, in transition or non-pathological when DSM-IV criteria were employed as the conceptual referent. The results also describe the prevalence of a variety of social and emotional problems associated with adolescent gambling. Finally, the discussion examined the normalization and contemporary social context of gaming and the impact of these influences on the measurement and identification of pathological gambling.

Laying the foundation for quantifying regional exposure to social phenomena: considering the case of legalized gambling as a public health toxin.

This article reviews the current status of gambling epidemiology studies and suggests that it is time to move from general population-prevalence research toward the investigation of risk and protective factors that influence the onset of gambling disorders. The study of incidence among vulnerable and resilient populations is a road yet to be taken. In this review, we briefly introduce the history of the field and thoroughly review the epidemiologic research on disordered gambling before providing a critical assessment of the current diagnostic tools. Overall, the extant research shows that disordered gambling is a relatively stable phenomenon throughout the world. Given that certain segments of the population (for example, adolescents and substance users) have elevated prevalence rates, we suggest focusing future prevalence studies on groups with apparently increased vulnerability. Moreover, we suggest that, for the field of gambling studies to progress, researchers need to take the road less travelled and examine more carefully the onset and determinants of disordered gambling. That said, given the problems with the current diagnostic screens, investigators need to refine their theoretical concepts and the epidemiologic tools used to examine them before the field can travel down this new road.

Understanding the means and objects of addiction: Technology, the internet, and gambling.

Exposure and adaptation models provide competing perspectives of the environmental influence on the development of addictive disorders. Exposure theory suggests that the presence of environmental toxins (e.g., casinos) increases the likelihood of related disease (e.g., gambling-related disorders). Adaptation theory proposes that new environmental toxins initially increase adverse reactions; subsequently, symptoms diminish as individuals adapt to such toxins and acquire resistance. The authors describe a new public health regional exposure model (REM) that provides a tool to gather empirical evidence in support of either model. This article demonstrates how the strategic REM, modified to examine gambling exposure, uses standardized indices of exposure to social phenomena at the regional level to quantify social constructs.