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COMPLICITY ON THE RIVER BANK: THE SEARCH FOR THE TRUTH ABOUT PROBLEM GAMBLING: REPLY TO THE COMMENTARIES

2005; Wiley; Volume: 100; Issue: 9 Linguagem: Inglês

10.1111/j.1360-0443.2005.01219.x

1360-0443

Jim Orford,

Mental Health and Psychiatry

It is a privilege to have been asked to reply to the commentaries from five people on my contribution, each of whose work on gambling and problem gambling I have been stimulated by in the past (Abbott 2005; Blaszczynski 2005; Rönnberg 2005; Room 2005; Shaffer 2005). The positions they take in their commentaries are diverse, but one thing is clear – publicly and politically gambling is newsworthy and controversial, and professionally gambling is calling the attention of students of addiction. It raises in a new form some of the long asked questions in the field. What is addiction? When there is associated harm, does the mischief lie in the product or in the people? (to paraphrase the early eighteenth century Dr John Jones, cited by Kurland 1978). Is the relationship between exposure and harm a straightforward one? Between the liberty of the individual citizen and the responsibility of governments to protect the citizen from harm and exploitation, where does the right balance lie? Can there ever be an effective alliance between those who purvey the product for profit and those whose business is the promotion of health? Is money for research always tainted if it comes from the industry? First I must take issue with Blaszczynski who challenges the very idea of gambling addiction on the grounds that gambling, unlike substances, involves no direct action of an external agent on neurobiological and cognitive processes, and that a gambling problem may be better thought of as an impulse control disorder. The evidence that individuals can become so strongly attached to gambling that they find it difficult to stop despite the multiple harms that it is causing is substantial, widespread and longstanding (e.g. France 1902; Orford et al. 2003). The evidence that excessive gambling can spoil people's lives is really incontrovertible. Whether one wishes to call that state of affairs an ‘addiction’ or an ‘impulse control disorder’ seems to me of little consequence. That question, although it exercises those who compiled the American Psychiatric Association's Diagnostic and Statistical Manual, with its 400 or so diagnoses, is a red herring in my view and simply serves to confuse debate. As Shaffer states, a complex and interactive model of causation has evolved in the field of excessive appetitive problems, and gambling is no exception. Alongside the cognitive processes to which Blaszczynski refers, advances are being made in understanding causative factors of social, personal, learning and biological kinds. In the latter area, research in the last few years is suggesting a role for brain systems including mesolimbic reward motivational systems and frontal cortical inhibitory or self-control systems (Lubman, Yücel & Pantelis 2004), in a way that suggests the distinction between excessive appetites involving the ingestion of substances and those that involve behaviours with strong nervous system effects is unhelpful. Indeed as one cognitive neuroscientist, active in the gambling area, has put it, one of the attractions of studying a behavioural addiction is that it, ‘. . . can serve as an informative model for substance dependence since it represents a similar addictive disorder, but it does not carry the confounding issue of exogenous drug effects on brain substrates’ (Bechara 2003; p.44). It surprises me that Blaszczynski believes that a separation can be made between people with psychiatric disorders such as manic depression or schizophrenia, who are vulnerable to uncontrolled gambling, and all the rest of us who can be expected to make an informed choice about gambling. Quite apart from the comfort that would give to the gambling industry, it seems to be contrary to most ideas about the complex nature of maintaining or losing control over behaviour and the dimensional nature of loss of control and dependence. Both Abbott and Room strongly make the point that when an organisation, whether industry or government, is dependent on gambling revenue, then it is comforting for them to believe that gambling-related problems are due to another mental disorder or to an individual character defect. The temptation to attribute an addiction such as gambling to causes internal to the person, and to neglect external or situational determinants was pointed out nearly thirty years ago by Cornish (1978), who compiled what was probably the first comprehensive British account of problem gambling for the Home Office Research Unit. The leading situational theory is exposure or availability theory. I am surprised that Shaffer considers it only to be a hypothesis that may or may not be accurate. The evidence for the importance of availability has been considered by official review bodies in Australia (Australian Productivity Commission 1999), the USA (National Research Council 1999) and the UK (Gambling Review Body 2001). Each concluded that increased availability of opportunities to gamble was associated with more gambling and more problem gambling. Amongst the evidence is a particularly thorough study carried out before and after the opening of a new casino in Niagara Falls, Canada, by Room and colleagues (Room et al. 1999; Turner et al. 1999) and a study of household expenditure on gambling before and after the inauguration of Britain's National Lottery (Grun & McKeigue 2000). I accept that the relationship between availability and problems is unlikely to be completely straightforward, although I wonder if Nevada might have special features that might make it an anomalous case. Shaffer favours instead a theory that I have not come across before which he refers to as the adaptation hypothesis, suggesting that people gradually adapt to the temptations and hazards associated with the potential objects of addiction. There is a moral element to it since facing such risks successfully builds character and self-control. The character building discourse around gambling is rarely heard these days but has been very evident historically (Reith 1999) and in sociological accounts of the 1960s and 70s (e.g. Goffman 1967). Abbott says something similar, although in different terms, when he suggests that the prevalence of problem gambling may level out and decline, even in the face of increasing accessibility, with the help of public awareness, expanded services for problem gamblers, and regulatory, industry and public health measures. But of course that is exactly what we do not have currently and are very unlikely to have on sufficient scale for the foreseeable future. To question the relevance of availability at a time when the UK, in line with global trends, is liberalising accessibility to gambling on a massive scale, whilst efforts at prevention and treatment for gambling problems remain miniscule, and to suggest that we can show strength of character by resisting the temptations, falls right into the trap laid by gambling industry lobbying. It is also at variance with the public health view that has come to be widely accepted when it comes to the consumption of products where there is a supplier (operating legally or illicitly) and where consumption can lead to harmful excess. I refer to the view that, complex and multifactorial though causation is, the more the product is supplied in an accessible form, the greater the volume of consumption and the greater the incidence and prevalence of harm. I doubt there would be many who would argue with that basic public health law when it comes to, for example, the supply of alcohol, tobacco and other drugs of various kinds. It would be very surprising indeed if that general rule were not also true for gambling, and the onus should be upon those who think gambling might be an exception to the general law to prove their case. All commentators on Britain's new gambling legislation, with the exception of industry representatives, think that the rate of gambling problems will rise as a result. The Government's Gambling Review Body acknowledged that it was a probability, and even the British Government subsequently has grudgingly admitted the possibility and, as a result, has set in motion a series of regular prevalence surveys and other studies to collect evidence on the results of the legislation. In anticipation of the new law coming into force (now expected some time in 2007), the Department of Health for the first time has begun discussions about how treatment services can be provided nationally for problem gamblers. I note that Abbott thinks it likely that the UK prevalence of problem gambling will increase in the short to medium term, perhaps a staggering three to four-fold, and that as a result there will be increased costs to families, communities and the wider society. It is surely our responsibility to challenge, on ethical grounds, government policy that is so widely believed to be putting individual and family health at risk. Shaffer thinks I am mistaken in portraying the gambling industry in stereotypic terms. He suggests that some segments of the industry are interested in public health. I accept there are differences in the stated positions of different parts of the industry. The same is true for the alcohol industry, and no doubt for the tobacco industry as well. We have been having a debate in the UK (Edwards 2004) about whether we should trust alcohol industry statements of concern for public health or whether we should acknowledge that the alcohol industry is a stakeholder group with basic interests that are in conflict with public health. My view tends to be in line with Room's when he writes of the complicity between the government and the gambling industry and the bargaining power that affords the industry, and with that of Rönnberg who writes of the dependence of governments on gambling taxes, and the dependence of the gambling industry on revenues from the minority of the population who will gamble most. Rönnberg cites a figure of around 3% of Swedish gamblers accounting for as much as a third of gambling revenue. That is in line with the Australian estimate I quoted that about one third of all gambling expenditure came from problem gamblers. The latter come disproportionately from those on lower incomes (Orford et al. 2003). Rönnberg makes a good point when he says it is unfair of me to attack the UK Government which is simply following global trends. But in Britain we still cling to the notion that our Government has some freedom of action over public policy, and the New Labour Government has developed a reputation for being very ready to respond to industry requests to remove controls on its operations. Shaffer writes of the likelihood that gambling has worthwhile benefits. Rather strangely he draws a parallel with drinking small amounts of alcohol and having sex, both of which he suggests may be good for the heart! I must say I struggle to see the equation with sex, but there is a lot of evidence that certain forms of gambling are associated with heart rate increases, so moderate gambling might be good for the health of the heart in that sense. But then I am sure there are many other ways of increasing heart rate, not all of them to be encouraged. I am not so naïve as to think that gambling could be eradicated from society, but I am not convinced that we would be worse off if it were. The Australian Productivity Commission (1999), in its most comprehensive review of gambling and society, made a valiant attempt to cost the benefits to society of gambling, but their argument was tortuous and unconvincing in my view, resting on the debatable concept of consumer surplus and depending on a crucial parameter, the elasticity of demand, that could only be estimated very approximately. Shaffer acknowledges that a government is responsible for protecting its citizens against known harms, and raises the often debated question of where to strike the balance between liberty and regulation, rather implying that he would strike the balance more towards liberty than I would in the case of gambling. One of the best discussions of this issue in relation to health behaviour that I have seen was a paper by Alonzo (1993). He started by citing the well-known prevention dilemma analogy of a river where people are repeatedly being rescued from drowning, until someone has the bright idea of going upstream to see why people are repeatedly falling in (or are they being pushed?). At the end of a longish paper that considers issues of detection, prevention, protection and health promotion, Alonzo amusingly elaborates the river analogy. The ‘doctor’, thoroughly confused by the mixed messages that he gets downstream, about why people need rescuing (and indeed whether they want rescuing at all), finally asks, ‘What is going on upstream?’ ‘He stoles up the rivers edge to see who is letting these people into swim. He finds Mr Profits and Ms Rights, a.k.a. Ms Least Restrictive Alternatives. Mr Profits is a very pushy person, and Ms Rights can be quite ornery and contradictory at times, but always stands up for herself. The doctor wants to find out who these people are who want to drown, perhaps he can screen for the drowning prone person, so he can tell the gate keepers not to let them in. Ms Civil Liberties says, ‘Can’t do that’. But Mr Profits thinks that is a great idea, he would not have to pay as much for liability insurance on risky swimmers. The doctor, even more confused than before, wants to know who set up this crazy swimming beach. Mr Profits says ‘It's what the people want’. Ms Rights says, ‘Yes, people need to have this kind of place, but sometimes people, like you Doc, come here and try to close the place down because it is causing too much of a disturbance to the community. Rumor has it the community is right some of the time, we need to screen for drowners, and we can either keep out the non-swimmers with ordinances or give free swimming lessons’. The doctor, after hearing all this, jumps in the river not knowing whether he should feel he has a right to drown or has the obligation not to drown. As he finishes his swim, however, and is trying to get out of the river, he notices Mr Profits casually pushing in tired swimmers who are sitting by rivers edge and then offering to sell them a life saver!’ (pp. 1031–32). I leave the reader to decide what parts in that story I, the commentators on my article, the British Government, the gambling industry, and all the rest of us are playing. Room raises the question, all-important for readers of Addiction, of the possible complicity between industry, government and other research sponsors, and researchers themselves. My experience, like Room’s, is that the gambling industry is keen to focus the research agenda on the ‘small minority’ of people who are ‘pathological’ and to define the pathology in such a way as to make prevalence look as small as possible. Abbott thinks I have been unfair in criticising the recommendations of the report he and others prepared for the new Responsibility in Gambling Trust (RiGT, UK; Abbott et al. 2004) for focusing research recommendations on problem gamblers and their treatment. I may have been presumptuous in suggesting that what was recommended was a focus on the individual-personal causes of gambling addiction, and if so I apologise, but I continue to believe that insufficient place was given to focusing on the harm potential of gambling products themselves and, secondly, on public opinion about the place of gambling in British society. Currently the RiGT, funded by the gambling industry, has set up a partnership with the Government-funded Economic and Social Research Council (ESRC) to launch a programme of research based on the Abbott et al. (2004) recommendations. The research community will be watching very carefully to see how decisions about research funding are made. Let us hope that Room's concern about complicity proves to be unfounded and that my worries are misplaced. Finally, let me dare to touch on some bigger issues – of science, truth and policy! Abbott is quite right to say that my article was meant as a catalyst for debate. The model I used was (Room 2004) a forceful article on alcohol strategies and policies for England. The editors asked me to remove some of the stronger language that appeared in my first draft. Even so, Abbott found, ‘. . . scanty supportive documentation in places and black and white portrayals when reality is in many shades of grey’. This prompts me to ponder the nature of scientific truth, and to ask at what point we should conclude that ‘the science’ justifies taking a position on policy. Although I would not describe myself as a social constructionist, I do see in our field good examples of the way in which ‘the evidence’ is marshalled in particular ways to support particular versions of ‘the truth’ (Gergen 1999). One of the prime examples in recent British gambling debates is whether there is evidence that children and young people are specially vulnerable to the development of problem gambling, and specifically whether it is harmful to play low-stake/low prize gambling machines (traditionally included in the category ‘amusements with prizes’, now to be called type D machines, continuing to be legal for children to play in Britain, unlike anywhere else). My reading of the evidence is that it is overwhelmingly in support of the view that children and young people are particularly vulnerable to problem gambling, the evidence coming from numerous studies in a number of countries. Indeed I have concluded that the vulnerability of the young is one of the very best established facts in the gambling field (Orford et al. 2003; Orford 2004). I am surprised therefore that Blaszczynski in his commentary should question that conclusion, arguing that prevalence rates amongst young people have been inflated. In my article I referred to the Government-sponsored review of young people and gambling in Britain which I was not alone in believing had read the evidence in a biased way, also concluding that the evidence on harm to young people and gambling had been exaggerated (our critique of that report has since been published, Griffiths & Orford 2005). Governments take positions, using ‘evidence’ in various ways. I believe it is our responsibility, as those privileged to have access to certain forms of knowledge which others may not have, to point out how we think evidence is being used to support a position that puts the unsuspecting at risk, and to take a position that we consider to be in the public interest. Since I wrote my article, there has been a UK General Election. The Gambling Bill just got through in the ‘wash-up’ period before parliament was dissolved. Although most of the Government's proposals are unchanged, there have been some significant changes in response to concerns of both Houses and lobbying by charitable organisations and health professionals. Notably, there will only be one of the new regional casinos with type A machines in the first instance (as opposed to an unlimited number, later reduced to eight), and Christmas Day will remain gambling-free!