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		Proceedings of the 19th annual conference on prevention, research, and treatment of problem gambling. June 23–25, 2005, in New Orleans, Louisiana. National Council on Problem Gambling, Washington, DC. Session II: Critical issues in problem gambling prevention, public health, and policy A public health perspective Presenter: David Korn (Introduction.) Loreen Rugle: I'm very happy to moderate this section of the conference. I'm primarily a treatment person. But as I've gotten more involved in councils, and states' issues, and funding, and how best to help people, it's certainly become increasingly ingrained in my awareness that we need a paradigm, a way of looking at these issues. Looking at public health perspective, how that interfaces with public policy, can inform public policy and policy makers, and what we need to consider in terms of prevention, and how complex and intertwined all of these topics are, is an increasingly interesting area for me. So even though it's the end of the day, and you've sat through a lot, I think this is going to be an intriguing and practical and informative session, and I hope you have lots of questions that you're already waiting to ask the panelists. We begin with Dr. David Korn. David is an addiction specialist, a public health physician, head of the Public Health Gambling Project in the Department of Public Health Sciences, Faculty of Medicine, at the University of Toronto, previously in charge of public health for the province of Ontario. He comes with a rich background to gambling, and has had a successful career in the area of public health. He brings a richness to the field of gambling that we've all been able to benefit from. So he will be starting with an overview from a public health perspective. David Korn: Thanks Lori. Good afternoon everyone. Thank you for coming to this session at this time of day, a kind of half punishment. I'm going to speak a new language. It's not Canadian. It's public health. So I hope it won't be conceptually too mind-bending for you. I want to thank the organizers, the National Council, for the invitation to come to your country, and to be a participant on this panel. What I would like to do in the next 10 to 15 minutes is just walk you through some concepts that are public health related. Over the period of time that I've worked in the gambling field, it's been my sense that there are many people who intuitively feel that this is a public health matter, but they haven't been able to find the language to communicate or conceptualize this. I guess that's my task as the introduction to this panel, to provide that kind of framework. Perhaps as a result of this, you'll have some new language for yourself that might resonate. It might give you some ideas around healthy public policy, and programs in the gambling field. Though this is a brief presentation, I did want to acknowledge a couple of other people that I've done some of my writing with, in this area: Howard Schaffer at Harvard University, my good friend Harvey Skinner at the University of Toronto, and Jason Azmier and Robert Gibbons at the Canada West Foundation in Alberta. They've been colleagues on a number of papers that we've written together. So what I'm going to do in the remainder of my time is just talk to you briefly from a public health perspective about the value of this perspective, public health determinants, and strategic goals, again from a public health perspective, and to propose a framework for action planning. I want to begin with a small story. A former colleague of mine from the Smallpox Program, the late Dr. Jonathan Mann, who became the professor of social justice at the Harvard School of Public Health, was fond of saying that what you do about a problem depends on how you frame it. So that's the crux of positioning this as a public health issue. There are lots of different ways of framing, which can be extremely valuable. This is simply another way of talking about and looking at the issue. So when you think of gambling, what does it connote for you? Does it connote a problem? An epidemic? A compulsion? Some public health issue or threat? A disease or a disorder? Entertainment or a leisure time activity? Or a significant revenue stream for your particular state, local government, or tribe? So again, how you think about this will likely determine what you do about it. When I talk to some people, and to some of my colleagues who are in public health, about public health, they say, "It's an intriguing way of thinking about things," but they're concerned that people really don't understand it. So let me just take a second and give you my definition of what public health is. Public health is the study of the determinants and distribution of disease, disability, and death in a society, in specific populations, and then the organized efforts to prevent, eliminate, or control the occurrence or spread. So half of that definition has to do with science, and the other half of the definition has to do with public health practice. So with that as our background, what's the value of this? Why even try and do this from a public health perspective? Why think about this from a public health perspective? I think there are some advantages in doing it. First of all, as with alcohol, public health folks talk not only about problem and pathological gambling, but gambling as a whole. So it brings a broad view of gambling as a whole. It has an upstream emphasis, meaning the emphasis is on prevention and health promotion. There's a commitment to partnerships. Public health people tend to do things in collaborative ways. A values commitment to engaging stakeholders, regardless of what the stakeholders' position might be. Multiple interventions. So it's one size doesn't fit all, and bringing better outcomes by combining appropriate interventions to achieve public health goals in the gambling field. At the end of the day, the bottom line is, "Does it do more good than harm?" That's the critical debate in the gambling field, individually, within communities, and from a healthy public health policy perspective. If there's time today or tomorrow, that's one of the things probably we could discuss in some way. I want to emphasize that public health is embedded in a notion of public health sciences. It has to do with public health practice, public health research, and public policy. But it's embedded in science. The driving force for public health and gambling is epidemiology. That is the basic tool. There are people in this audience who have distinguished reputations for their work in the area of prevalence studies. Epidemiology is probably the key and the central science that backs up public health practice. All of the discussions on costs and benefits are underpinned by the notion of, "Exactly what's the prevalence rate here? And how does that play out in community and population terms?" The second science that goes with public health is something called population health. Some of you might understand that. Some of you actually probably come from universities where they have departments of population health. For others, it might mean nothing at all. But basically, that's looking at particular groups, at risk groups and subpopulations, to see how they are affected by gambling and gambling-related harms. So it's population health. In addition to that, health promotion plays a big part. Health communication, health economics, are all critical, with people with expertise in these areas to bring their savvy to bear on how these problems are discussed. Let me spend a few minutes on the determinants of problem gambling from a public health perspective. There are four of these determinants that I'll talk about briefly. At the top of the pyramid is the gambler. On one side are the games that people gamble. On the other side is the gambling environment. Then, sandwiched between the gambler and the games, is money or something of value. So those are the four public health drivers to understand and to think about how gambling plays out for individuals, for special populations, and for communities at large. Some of you in the audience have backgrounds in public health, and you'll recognize where this comes from. It's the classic public health model of agent, host, environment, and vector, used to describe control measures for various communicable diseases. Historically, for things like malaria. More recently coming from Toronto, that's the model, in terms of determinants, that was used to develop the strategies for SARS [severe acute respiratory syndrome]. So you can talk about SARS in this regard. You can talk about malaria. But probably more importantly for us, it's also the model that's been used in the addiction field. Many of you are familiar with the notions of drug, set, and setting. In the tobacco wars now in the States, this is the model that everything turns on. It has to do with the smoking environment: big tobacco and the advertising and marketing practices that are being played out within your justice system at this point and time. So it equally applies to gambling. My view on what's been happening so far in the conference is there's been a lot of focus on the gambler. The gambler's biology. The gambler's behavior. The gambler's psychology. I'm going to suggest that there's a lot of value in looking at not only the individual dimensions of the gambler, but their social dimensions. Their age. Gender. Socioeconomic status. Ethnocultural background. All of these things play out in important ways. In other areas of health, it's well understood now that the social determinants, not so much the individual determinants, are extremely powerful in predicting health outcomes in a whole range of conditions, from heart disease to cancer to various addictive behaviors, as well. My encouragement and appeal to people, is to look carefully at the interactions between the social dimensions of a gambler and the gambling environment. Embedded in the gambling environment, obviously, are the gambling industry, the Internet, family, community, peers. Look at the relationships between the social dimensions of the gambler and the gambling environment, and lots of good ideas worth testing will come out of those dimensions. Determinants of public gambling. Why am I dwelling on this? I'm dwelling on it because this is a complex web of interaction. Alex and the other people throughout the day have talked about the complexities, the web of connection that's between the gambler, the gambling environment, and the games. It gives you hints as to how you deal with it, in terms of interaction strategies. Let me talk for a second about gambling strategies. A notion from Alice in Wonderland: "If you don't know where you're going, any road will get you there." So whether you're working with clients in treatment, or you're working within agencies in the community, or at a policy level, goals clarification is important—both broad conceptual goals, and where possible, putting numeric indicators to these with specific objectives. Public health is about health promotion, prevention, and community protection. I framed broad goals within those three themes, to promote informed and balanced attitudes, behaviors, and policies towards gambling and gamblers, given all the stigma; to prevent gambling-related health problems; and to protect vulnerable and at-risk populations. That last one being the whole area of high-risk populations that I mentioned. Within that, you can speculate on targets that you might want to consider around prevalence reduction, not only for the general population, but also for at-risk populations. So I'll finish up with introducing a framework for public health action. I want to talk about what's at the bottom part around harm reduction, prevention, and health promotion. There's a range of health interventions. But let me work down. In the middle, you'll see the green, yellow, and red that reflects the range of gambling behaviors, and some rough approximation of the distribution of gambling behaviors in the general population. So given everything you've heard, I'm introducing some more language, health language around gambling. So you have the green nongamblers; that large yellow swath, which are the healthy gamblers; then at the other extreme, towards the apex, unhealthy gamblers. Roughly, in terms of the distribution of the population, and I'm just using this in broad terms, fifteen percent of the population don't gamble. Eighty percent of the population gamble, either with no, mild, or moderate problems perhaps. Again, just in broad terms, five percent of the population have severe problems. So the question is, where do you want to put your time and resources, in terms of the biggest bang for your buck? If you're a clinician, you want to work with people that have severe problems, to help them. But there are other ways of talking and thinking about this as part of an integrated approach. Public health people have a tolerance for a high level of ambiguity. So rather than a clinical view of sharp demarcation points between pathological gamblers, problem gamblers, social gamblers, public health folks often will talk about continuance. So at the top you'll see a continuum of problems that range from none, to mild, moderate, and severe. You could also have a risk continuum that provides some background for looking at the interventions—the rest of the talks for today and tomorrow. So in addition to treatment, you'll see primary and secondary prevention. The primacy of prevention, I think, is what public health is all about in the gambling field. Perhaps less familiar are notions of harm reduction. It has been, in the United States, a controversial area, because it's been associated with treatment goals. It has introduced the concept in the treatment area of moderation, in addition to abstinence goals for patients and clients you're working with. I feel that Alex's work around machines, electronic gaming machines, is pure harm-reduction strategies in the best sense of the word. There are other examples, as well. So introduce the notion of harm reduction. Lastly, I'll finish up by talking about health promotion. Notice it's at the green end of the continuum that has to do with processes to enable and empower people to make informed choices about their gambling and gambling-related risks, to build on their assets, and the capacities of themselves, family, and community members, to allow people and support people to enjoy this activity, if they choose to. The research that we do at the Public Health Gambling Project at the University of Toronto is almost exclusively health promotion research. We have a Web site, youthbet.net, and a recent project that we finished up, looking at commercial gambling advertising and its potential impacts on young people, that are pure health promotion. It's a big area for many of you; it's probably quite foreign to you. But it's a worthwhile way of looking at and working in this area of gambling. Thanks. Loreen Rugle: Let me ask this. In terms of health promotion, do we really need gambling-specific health promotion efforts? Or do we just need to fund general health promotion activities that will immunize people against a whole range of problems? David Korn: It's a huge debate, and has to do with a number of assumptions. Just to give you my perspective on this: I'll maybe come at it sideways first. In the gambling field, we have a lot of discussion about high-risk populations, and what to do about it. [Unclear] populations, lower socioeconomic groups, youth, et cetera, et cetera, et cetera, homeless populations, as having high-risk, vulnerable, or special needs. I think there is a big debate in the gambling field about, "if you've got limited resources, do you have broad primary prevention strategies that enhance awareness? Or do you target your efforts to high-risk groups?" Most of the discussion that I've heard tends to lean towards targeting high-risk groups. If you look at some of the literature coming out of Canada, in the area, for example, of preparing children for school entry, there's good data coming out of British Columbia that suggest general approaches to healthy kids is a much more effective use of funds than targeting kids at risk. That's at school entry. Preparation for school entry. Other studies in public health in the Scandinavian countries suggest broad-based population approaches are worthwhile. But the problem here is that you need to do good studies. And so it's my opinion versus your opinion, or what we extrapolate from other areas. I think this is a significantly important area of research to try some of this out. Some of you may remember in the United States the big Mr. Fit, Multiple Risk Factor Intervention Trials, about 10 years ago. It spent millions and millions of dollars looking at this issue, and at different kinds of interventions versus a control group in broad societal terms. The control group did almost as well as the people that had all the interventions. We collectively have to think of research that asks this question, tries it out, and see what's the better approach. It's a big debate. Alex Blaszczynski: David, the public health approach is, in part, a provision of information and protective factors that, in essence, is the community and government initiatives, despite the fact that governments have conflicts of interest. But it also balances against the marketing, and the promotion, and the development of particular attitudes towards gambling. And, in particular, if we look at the Texas Hold'em, we're starting to develop an opposing force. How does the public health approach do with the particular marketing and promotion of particular products? David Korn: In the gambling field, the studies that have looked at advertising and marketing are almost nonexistent. We've just completed a study looking at commercial gambling advertising's potential impacts on young people, as a preliminary descriptive study. We couldn't find other studies in the literature, around this. When you think about how much money is spend on commercial gambling advertising, it's absolutely staggering, yet we don't know what the impact of this is. It deserves an enormous amount of study. In the tobacco and alcohol field, this is a highly researched area. And again, a lot of what's turning on the legislation, as in the case before the U.S. Supreme Court and the States, is turning on advertising and marketing practices. So I think this has to be looked at extremely carefully. My personal view on this is we have to communicate better, at least as a beginning place, that gambling itself is a risky behavior. Most people do absolutely fine, but it's a risky behavior. I think commercial marketing doesn't really want to convey that message, at least easily. But we need a ton of research in this area. It's a wide open field. It's important, in my view. Alex Blaszczynski: Just on that particular point. The Australian Gaming Machine Manufacturer's Association published and distributed a player information booklet. Within that booklet, it states specifically that gambling is for entertainment. It's not to establish revenue. In the short term, it is possible to win. But in the long term, the more you play, the outcome is virtually impossible, and exists only in the most extraordinary circumstances. So this is the statement that the gaming industry has, in terms of player information. Then, balanced against that is, "Win cash. Win. Everyone's a winner. You've got to be in it to win it." So you have these contradictory messages that occur. And I think it's the important element here, as in other public health areas, less the information, but the significance of attitudinal shifts, which ultimately will lead to behaviors. The community doesn't have the resources that the gaming industry does, in terms of promoting a product that for some is potentially dangerous. Rachel Volberg: I'm going to take this back again to the question of advertising. Because I do think it's an area of the gambling environment that has received a woefully inadequate amount of attention. I was able to be involved, over the past year and a half, in a significant set of literature reviews. I was struck that there have been three studies of prevention and public awareness campaigns. Three studies. One in Manitoba. One in one of the states in Australia. One in the north central United States, Minnesota, I believe, or Indiana. And the lesson learned from those three studies was that the campaigns to raise public awareness about problem gambling and provide some prevention were completely outclassed and outspent by a factor of something like nine or ten to one by the campaigns to promote gambling. And David, I'm wondering if you might comment on the tobacco, and the alcohol, and the other public health campaigns, and how that issue might have been addressed. David Korn: I haven't done my research, or I'm not familiar with the research literature, in any detail, in the tobacco, and in the alcohol field. But there have been a range of studies that have been done. There's good literature on it. I just don't have it at my fingertips. I think that the challenge, Rachel, is that these are quite difficult studies to do. They usually raise more questions than they answer. If you use sophisticated methodologies, it takes a ton of time, and a ton of money, to look at whether they're effective. Most of the stuff that I've seen, and some of this that I'm kind of involved with, as well, tend to look at changes in knowledge, attitude, and behavioral intent, with or without a control group. I guess that's a place to start. But we've got to get a lot more sophisticated than that in developing counterforce messages that are worthwhile. So I think we have a long ways to go. [End of session.] For correspondence: david.korn@utoronto.ca

		issue 15 — december 2005