Prevalence of Problematic Gambling in South Australia: A Population Health Perspective

Abstract

This paper was designed for a public health readership, rather than for the traditional gambling research fraternity, in order that it might reach people working in the wider primary health care field who have an interest in the social, political, and philosophical implications of the emerging phenomenon of modern problematic gambling and gambling disorders in our community.

In various iterations of standard prevalence studies designed to determine the number of people in defined populations who are adversely affected by gambling to the extent that they would register a DSM 5 diagnosis for gambling disorder, findings are consistent over time. That is, around 3% of the population is at severe or moderate risk of having a gambling disorder.

Given that up to ten other individuals may be impacted adversely by the behaviour of each problem gambler in the community, and suffer the negative consequences of this affliction, the implications for society are clear. Gambling disorder, a preventable condition in essence, has a substantially negative impact on society and requires significant resources for remediation; resources that should rightly be drawn from the industry that profits from gambling and from governments that rely on the inexorably increasing revenue streams flowing from the expanding gambling industry.

In contrast, however, resources flowing back to the afflicted in the community are sparse indeed, with South Australia’s Office for Problem Gambling, for example, managing an annual budget of around $5m to support people seeking help for their gambling problems. The challenge for service providers in this context, therefore, has been to achieve the best treatment outcome for each person seeking help for their gambling problem and at the lowest possible cost, hence the current search for efficiency and cost effectiveness in treatment programmes.

What is known About This Topic?

It is currently accepted that around 3% of the Australian population is at moderate to severe risk of having a gambling disorder with around 0.7% in the high-risk category of problem gambling assessed by the DSM5. We know that the gambling industry is expanding in size and complexity, yet recent prevalence studies show no increase in problematic gambling behaviour.

What Does The Paper Add?

This paper adds a public health perspective to a specific problem gambling prevalence study conducted in South Australia and questions the logic behind the claim that the burgeoning gambling industry is producing fewer problematic gamblers even though the industry is expanding and providing easier access to gambling products via modern technological innovations such as on-line gambling.

What Implications are there For Practice in the Field?

The implications of this counter-intuitive phenomenon are that we need to look again at the impact of the gambling industry on the health and wellbeing of our society and assess gambling behaviour in the community in ways that are inclusive of the whole range of people involved in the industry. Perhaps the standard gambling prevalence survey is no longer yielding accurate information about the extent to which Australians are involved in and affected by the gambling industry.

Background

Gambling is currently defined as being a ‘problem’ for individuals if their gambling activity causes harm to themselves or to the people close to them [1-3]. Myriad scales and assessment protocols exist for classifying pathological gambling, problematic gambling and gambling disorder, the Diagnostic and Statistical Manual of Mental Disorders, for example, [4,5] and the Victorian Gambling Screen [6]. As summarized by Thomas and others.

‘A range of terms has been used to describe problematic gambling, including pathological, disordered, compulsive and problem gambling. In Australia ‘problem gambling’ is the most commonly used term and describes the situation in which a person has difficulties limiting money and or time spent on gambling, which leads to adverse consequences for the gambler, others or for the community [7].’

Work by Thomas et al has highlighted the paucity of evidence supporting not only the accurate assessment and diagnosis of ‘problem gambling’, but also shows considerable equivocation in relation to the efficacy of the various treatment regimens available in the market [8,9]. Indeed, there is limited evidence to support the use of the currently preferred CBT treatment option let alone there being adequate scientific support for the plethora of other treatment forms and permutations now emerging in response to the phenomenon of problem gambling, including approaches employed by psychologists, social workers and general counselors.

Gambling problems are often co-morbid with a range of other chronic conditions and ‘gambling disorder’ is now considered to be a mental health (addiction) disorder as defined by the ‘axis 1 diagnosis’ under the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) classification of mental illness [4,10]. Under these classifications, problematic gambling…

‘…is a chronic disorder that encompasses an unrelenting and recurring failure to resist impulses to gamble and where this ‘maladaptive behaviour disrupts, or endangers personal, family or vocational pursuits.’

To date, gambling disorder is not recognized as, or understood to be, a major threat to our social order or to public health and wellbeing generally. The concepts around the disorder are quite embryonic and ill-defined with the focus predominantly on the problem being the responsibility of the individual gambler along with the need, therefore, for provision of individualized solutions to such problems [11,13]. Generally, the gambling industry is seen as benign in the scheme of things and those who fall victim to its products as flawed in their own personal way. The implication being that the diagnosis of gambling disorder is the result of a personal fault or weakness linked to other co-occurring mental health disorders and, therefore, no responsibility for such consequences need rest with the gaming industry or with those who might profit from it.

These key questions about the responsibility of the industry or the industry’s contribution to gambling problems are yet to be addressed satisfactorily and current deficiencies and inadequacies will need to be resolved if the assessment and treatment of people with gambling disorders is to become a more robust and reliable science than is presently the case. Currently, for example, gambling help service providers are striving for clarification about what constitutes a problem in the context of gambling behavior and whether so called problems are defined by behavior or by the financial and harm impacts that the problematic behavior has upon individuals, their families and society in general. The question of whether disordered gambling is best viewed as a mental health disorder, similar to an addiction, remains open in spite of the DSM 5 release, depending on which view of the condition is assumed or which ideological stance is taken in relation to it. Indeed, there is considerable opposition to the notion that gambling disorder is becoming so narrowly defined and that the wider social and psychological contexts of individuals are not taken into account when assessing whether a person has a treatable problem or not [14].

Further, given that problems do exist in relation to the business of gambling, the question of how to identify, assess and test for these problems remains while the nature and extent of the problem is unclear. Some suggest that problem gambling can be cured in the long-term while others argue that so called ‘treatments’, such as therapy and counseling, just ease the problem, perhaps even displace it, and that therapy is not a realistic option generally or in the context of gambling disorders specifically [15]. Whilst there is emerging evidence for therapeutic effects of a range of treatments, it is also likely that the vast majority of the impacts or effects of treatments may be due to non-specific effects [16,17] making it even more imperative that we define our diagnoses and test our treatment programmes more rigorously.

The fact that so few people with gambling problems seek help for their affliction needs to be considered with a view to understanding why some people are ‘help seekers’ while others do not seek such support. In the domain of treatment, the question of whether it is best to plan to control a person’s gambling or attempt to eliminate the desire for it all together remains unresolved [18]. Relapse to problematic gambling is a common phenomenon about which researchers know very little [19] and the complex nature of the disorder means it is inextricably linked to other co-morbid mental health conditions [20]. There remains, therefore, an open debate about whether ‘problem gamblers’ might naturally recover from their problem over time [21] and as their circumstances change in a natural course of events where formal treatment is not required [22,23].

The answers to some of these contentious questions around the phenomenon of problematic or disordered gambling are being explored [24], but in the interim and while we evolve a more adequate taxonomy of disordered gambling and potential treatment modalities, policy makers need to be guided as to whether problem gambling, like problem smoking, drinking or eating [25], has the potential to become a major health issue. The question as to whether the burgeoning industry surrounding gambling is likely to visit more harm upon society than is acceptable or affordable is pertinent. Put another way, does the capital benefit accruing to businesses and the State from gambling really justify the proliferation of the industry in its various forms along with the subsequent harm inflicted upon the community and individuals in the process? It is known, for example, that around 2-3% of the population of Australia experience serious problems with their gambling [26], but also that only around 3% of individuals in this ‘at risk’ population actually seek assistance for their problem in any one year. That is, the gambling help industry, as it currently exits, reaches around 3% of problem gamblers. A more optimistic assessment puts the figure at less than 10% for South Australia.

For diabetes management, in comparison, estimates are that one out of every 2 people with diabetes will know about their condition and, consequently, seek assistance for it. Therefore 50% of diabetes suffers are aware of their illness and seek help accordingly via their GP and the community health system. Perhaps this ‘strike rate’ could be a guide for managing gambling disorder as the population prevalence of gambling addiction and type 2 diabetes is similar. To compound matters further, some authors suggest that current approaches to treatment for gambling disorders may discourage people from seeking help and adhering to structured treatment regimens [18,29].

SA Survey Approach

The in-scope population for the recent prevalence survey was South Australian residents aged 16 years and over who were contactable by either a landline or mobile phone. Data collection was via Computer Assisted Telephone Interviewing (CATI).The survey used a dual-frame sampling methodology (i.e. a sample design that utilises both landline and mobile phone telephone numbers), which resulted in 7,133 interviews being conducted with respondents who were part of the randomly generated landline sample and 2,375 interviews with respondents selected from a list-based mobile phone sample. The inclusion of mobile phone users (20%) in the survey was intended to compensate for the inadequacies of previous surveys that concentrated on land line / home phone contact numbers only.

All results were adjusted for uneven distributions and, for the 2012 profile, the gambling frequency across a range of gambling activities was reported as being very similar to the findings of the previous 2005 survey where around 69% of the sample had had some involvement in some form of gambling in the previous year, 68.8% in 2012 and 69.6% in 2005.

Key Findings

There was little change in problematic gambling prevalence profiles from the previous survey compared to that of 2012. For the classification of ‘problem gambling’ in 2012 using the Problem Gambling Severity Index (PGSI), 0.6% were classified as having a gambling problem (8 or above on the PGSI scale), 2.5% with a moderate risk (3-7 on the PGSI) and 7.1% as low risk (1-2 on the PGSI). That is, 3.1% of the SA population was classified as having either severe or moderately severe problems with gambling. A National prevalence survey conducted by Gainsbury et al produced similar distributions of at risk and problematic gamblers showing that the prevalence rate of problem gambling among the Australian adult population was 0.6%, with an additional 3.7% of adults experiencing moderate gambling-related harms. Among those who had gambled in the past 12 months, 1.0% were classified as problem gamblers and a further 5.8% gave responses indicating that they experienced moderate gambling related harms [31]. The 2014 Victorian prevalence study produced similar estimates for proportions of ‘at risk’ gamblers [26].

From clinical reports [32,33], and other studies, we know that the majority of disordered or problematic gambling diagnoses are associated with access to and use of Electronic Gaming Machines (EGMs) with around 6000 venues offering EGM access across Australia while the social cost of gambling in Australia is estimated to be around $5b annually.

Internet Gambling

The nine internet gambling participation questions used in the 2012survey were designed to derive an overall measure of internet gambling prevalence; those who had participated in one or more of the activities shown during the last 12 months were classified as internet gamblers. The 2012 South Australian study shows an internet gambling prevalence of 5.3% for South Australian adults. This compares with a reported prevalence of just 0.5% for the 2005 survey (NB this survey did not access mobile phone users who would be younger people). It also compares with an estimated prevalence of 14% for any form of on-line gambling by UK adults as reported for the 2010 British Gambling Prevalence Survey [35], however, this figure was inflated by the relatively high level of on-line purchase of tickets in the National Lottery (9% of UK adults). Using a more conservative definition of online gambling, which only includes those who bet online, used a betting exchange or gambled online on poker, bingo, slot machine style games or casino games, the prevalence of on-line gambling amongst UK adults was estimated at 7%.

Implications for Society

Clearly, significant numbers of South Australians have contact with the gambling industry in one form or another, with the most frequent contact being via lottery ticket purchases. In 2012, 26.5% of the population were estimated to have used EGMs, down slightly from 30.2% in 2005.

The Population Effects

Given that on-line gambling is an emerging phenomenon, which is yet to be accurately delineated in terms of its impact on communities and individuals, and that the more traditional forms of gambling such as EGMs and casino gambling persist and are continuing to compete in the gambling market, from a population perspective society is now subject to a higher level of exposure to gambling than in the past. Burgeoning industrial presence and exposure to gambling products mean that the adverse impacts of the business are also likely to be increasing. The results of this current prevalence survey in South Australia do not show this, however. Whilst some may argue that this growth in exposure to the product might serve to train or condition individuals and communities, in an evolutionary sense, to be better able to deal with the adverse effects of gambling as the industry expands, a less sophisticated view of the phenomenon would suggest that more of the product simply means more problems for the consumer.

Prevalence studies, like the one conducted in South Australia and described above, appear to be showing that there is no real increase in the rate of problematic gambling resulting from the obvious growth in the forms and functions of the gambling business. That is, more gambling paraphernalia in society does not mean more problems. So here is the rub. Are we measuring the incidence of problems in a way that accurately reflects the impact of this business upon consumers or are other factors at work in this environment? It has been suggested that prevalence studies may help to validate the gambling industry by identifying that a minority of people are ‘problem gamblers’, advancing the conclusion that the industry has minimal adverse impacts on society generally and a limited obligation to support those with problems [36].

As the world moves increasingly to build gambling industries upon which economies like Macau, Singapore, Sydney, and Adelaide are in part predicated, how is it that so little evidence is emerging about the adverse impacts of such growth in gambling activity? Are people simply not reporting problems with gambling because gambling has such a ubiquitous presence now that we have come to see participation in gambling as normal, like guns being normalised in a waring economy, for example?

Are we asking the wrong people about their gambling behaviours or are we indeed becoming inoculated to the effects of gambling and de-sensitized to it as the presence of the phenomenon in our communities grows? Perhaps we are simply asking the wrong questions about the gambling industry in our rather clumsy application of science to the overall phenomenon of gambling in modern society. Jane Jacobs in ‘Science Abandoned’ provides some excellent examples of how, for one reason or another, research that is focused on the wrong questions, distorts a community’s perceptions of reality. Such questions arise from inquiries into the impact of gambling as the prevalence of problem gambling appears to be stable at a time when individual and community access to gambling options and activities is escalating. Something is not quite right in this equation and this ‘something’ should be the focus of our ongoing inquiry into the effects of the expanding gambling industry as new waves of expansion impact upon countries like India and encroach further on cities like Sydney.

Are we becoming immune to the impacts of this industry in the face of a barrage of gambling related products delivered to us directly, easily, and effortlessly and in an ever-increasing range of formats or is the process of measuring and reporting the incidence and nature of gambling disorders in our community being influenced by other factors? Perhaps economic factors and the imperative for governments and the gambling industry to paint a much more benign picture of the effects of this business upon consumers of gambling products than is the case are skewing our collective perceptions of the larger things at stake. A comparative example of this phenomenon is the way in which our collective perceptions of health and wellbeing, along with our growing dependence on treatments and medications, may be skewing our concept of health and well being in general [38- 40].

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