The public health perspective on 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.1
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.2 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.3 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 VLT-related problem gambling.4 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 $895.1 million to $820 million respectively.5 The cost to the provincial government was a decrease of 11.4% in VLT revenues, from $132.6 million to $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.
• Consistently enforce the legal age of purchasing lottery tickets, given that a substantial proportion of adolescents participate in lottery ticket gambling.
• Regulate and possibly ban inexpensive gambling products that have instant play/reward (e.g., scratch tabs), since the immediacy of gratification may aggravate addictive behaviour.
• Ensure that future partnerships or contracts with casinos and other gambling businesses serve the public interest in both the short and long-term.
• Decrease the number of VLTs.
• Introduce a moratorium on new casinos.
It has been 6 years since the public health community recognized the expansion of gambling as an emerging issue in Canada. The public health community can help define the balance Canadians desire among the competing interests created by our society's endorsement of gambling. If gambling is indeed seen as a public health issue, we now need to develop a comprehensive and strategic approach that takes advantage of the full armamentarium of public health action.
Christiane Poulin Canada Research Chair in Population Health and Addictions Department of Community Health and Epidemiology Dalhousie University Halifax, NS