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Evaluating Responsible Gambling Programs in Emerging Gambling Markets
Debi A. LaPlanteDivision on Addiction, Cambridge Health
AllianceHarvard Medical School
Acknowledgements• Division on Addiction Colleagues
– Howard Shaffer, Sarah Nelson, Heather Gray, Matthew Tom, John Kleschinsky, Alec Conte, Layne Keating
• Division on Addiction Support– Foundation for Advancing Alcohol Responsibility, National
Institutes of Health (National Institute of General Medical Services), Indian Health Services, Commonwealth of Massachusetts DPH and MGC, DraftKings, & Tung Wah Group of Hospitals
Impact of Gambling Disorder
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Meaning Well and Doing Good
Public Health Program Evaluation
“Rigorous monitoring and evaluation, with mechanisms to avoid bias in the data or misplaced confidence in program effectiveness, are essential
for both progress and sustainability.”
Dr. Tom Frieden, Director of the CDC
Frieden, T. R. (2014). Six Components Necessary for Effective Public Health Program Implementation. American Journal of Public Health, 104(1), 17–22.
“Honest and transparent assessment of progress or the lack thereof--even or especially
if temporarily inconvenient or embarrassing because of lack of progress--is critical to allow continuous refinement of and improvements in
program strategy and implementation.”Dr. Tom Frieden, Director of the
CDC
Public Health Program Evaluation Cont.
Frieden, T. R. (2014). Six Components Necessary for Effective Public Health Program Implementation. American Journal of Public Health, 104(1), 17–22.
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How Should We Develop Responsible Gambling Programs and Practices?
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The Reno Model: Background
“A strategic framework should guide key stakeholders to develop socially responsible policies that are founded on sound empirical evidence rather than those that emerge
solely in response to anecdotally-based socio-political influences.”
-Blaszczynski, Ladouceur, & Shaffer, 2004
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The Reno Model: Principles & Assumptions
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The Reno Model: Responsible Gambling Strategies• Effective in
reducing the incidence of harms?
• Reduction leads to decreases in prevalence of harms?
Evaluation
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The 2004 Reno Model: Roadmap for the Future
• Establish a global body representing interests of all key elements and stakeholders
• Establish and agree upon definitions, terminology, and standardized measurements
• Coordinate a program of cooperative research that permits data sharing
• Develop resources than can advance the objectives of the spectrum of prevention efforts
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The Reno Model: Principles, Assumptions, & Ethical Underpinnings
Shaffer et al., 2015
AutonomySelf-rule and the
ability to make one’s own decisions
BeneficenceEfforts to be
helpful and to do good
Non-maleficence
Efforts to avoid doing harm
JusticeObligation to act on
the basis of fair adjudication
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The Reno Model: Responsible Gambling Strategies• Effective in
reducing the incidence of harms?
• Reduction leads to decreases in prevalence of harms?
Evaluation
Collins et al., 2015
Possible Consequences of Responsible Gambling Practices
• Decrease gambling-related problems• Increase gambling-related problems• Have no effect on gambling-related
problems• Influence gambling-related problems
indirectly through other factors– e.g., ironic interest increases
Seventh Inning Stretch Binge
Reducing Injury (and Bike Riding)
(Carpenter & Stehr, 2010)
Divergent Consequences for Gambling• Maximum Bet Limit
– less expenditure per turn– longer play
• *Slowing Reel Speed– play is slowed– play more aggressively
• Removal of Bill Acceptors– less expenditure in same length of time– less recognition of monetary loss
• *Won-Lost Displays– better understanding of monetary impact– chasing of losses
• *Self-limits– impulsive play reduced– players might play to notification, when
they otherwise would stop
• Random Time-Outs– provide gamblers a chance to assess– gamblers might increase drinking or
smoking behavior
*Adapted from Bernhard & Preston (2004)
What Do We Know About Responsible Gambling Programs and Practices?
How Can We Know About What Responsible Gambling Programs Work?
• Prospective research following gamblers pre- and post- harm minimization effort– Prospective research assessing which behaviors and
activities and gambling opportunities influence problems versus which reflect their problems, informing future harm minimization strategies
• Actual gambling behavior & less reliance on self-report
• Randomized Trials– Coordination with stakeholders for testing
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Evaluation Feedback & Reporting Loop
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Responsible Gambling: A Synthesis• Why?
– Responsible Gambling programs are operational around the world– Scientific evidence related to Responsible Gambling is limited and
methodologically weak• What?
– Identify the body of work that meet minimal methodological quality standards– Identify primary evidence-based RG strategies
• How?– Comprehensive literature review of peer-reviewed publications– Use a priori set of inclusion criteria to maximize external validity
(Ladouceur et al., 2017)
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Synthesis Strategy
1. Matched control or comparison group
2. Repeated measures3. One or more
measurement scales
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Synthesis Results
19992000
20012002
20032004
20052006
20072008
20092010
20112012
20132014
201502468
1012
RG Studies over Time
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Synthesis Results Cont.
9
8
5
4
3
Number of Publications by Type of RG Strategy
Self-exclusionBehavioral CharacteristicsSetting LimitsRG FeaturesStaff Training/responses
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Synthesis: Self-exclusion (n=9)• Self-exclusion is associated with improved psychosocial
functioning and assorted reductions in experiences of harmful consequences of gambling, at least in the short term
• 2 studies found that about 50% violate after initial enrollment
• Distinct gambling behavior characteristics of self-excluders might be used to develop predictive algorithms
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Synthesis: Behavioral Characteristics (n=8)• Individuals who have gambling-related problems
are identifiable by gambling behaviors• Gambling involvement, playing a diversity of
games, is a strong predictor of problems• Gambling behavior characteristics might be useful
to predictive algorithms, however, more research is needed
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Synthesis: Setting Limits (n=5)• Voluntary limit setting seems to be adopted by few• Limit setting might reduce gambling behaviors, but
exceeding limits might be a common occurrence• Although studies that identify the characteristics of
limit setters are important, more research on the impacts of limit setting are needed
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Synthesis: RG Features (n=4)• Message placement and message type (graphic/text-
based) might influence things like recall, perceived importance, and short-term gambling outcomes
• People might favor cash display over clock display or time-based pre-commitment
• Few people use RG features, but for most, they do not seem to detract from enjoyment
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Synthesis: Gaming Staff (n=3)• Imparting new knowledge to employees might be
easier than correcting erroneous beliefs• Employees are poor judges of gambling-related
problems among customers• Employees find responding to gambling-related
problems difficult (e.g., awkward, embarrassing, uncertainty)
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Synthesis: Summary• Responsible Gambling studies are limited, but in
many ways promising• RG programming activities might be ahead of
scientific support• More high quality research studies are needed,
including randomized trials and longitudinal assessments
Minimally-required Responsible Gambling Practices
• Population-based education• Staff training• Provision of helpline and treatment info• Limiting direct marketing to at-risk• Warning signs• Restrict underage• Restrict alcohol sales• Self-exclusion programs• Ethical advertising and marketing practices• Modify structural features that contribute to
excessive gamblingBlaszczynski et al., 2011
What Can’t Science Tell Us About Responsible Gambling Programs?
• Science can tell us the costs and benefits of a given regulation• Science can eventually tell us how problem gambling develops
and how regulations might intervene in that process• Science *can not* tell us how much weight to give to
individual liberty vs. governmental prevention of harm
Challenge to Us• Gambling creates opportunities to improve and
complicate day-to-day life– To be aware of the changes gambling might create– To navigate the changing opportunities safely– To rely upon evidence-based policies and programs that
minimize unanticipated outcomes
THE PLAINRIDGE PARK CASINO GAMESENSE PROGRAM
Evaluating Responsible Gambling in Massachusetts
MA Responsible Gambling Initiatives
Voluntary Self
Exclusion
Voluntary gambling
limits
• Voluntary self-exclusion• Who self-excludes?• What happens to those who self-exclude over time?• How can VSE be improved
• Setting voluntary gambling limits• Do subscribers to Play My Way evidence play patterns different
from non-subscribers?• Do subscribers to Play My Way evidence different play patterns
after subscribing
• Player education • What services do GameSense Advisors provide?• How do patrons perceive these services? • How does exposure to GameSense relate to RG knowledge &
behavior?
Evaluation of RG Information Centers
• RGICs are based on the idea that information will mitigate potential harms associated with gambling
• Ontario RGICs– visitors reported being satisfied with the information they received & rated staff
highly• Montreal RGIC
– RGIC visitors learned more about randomness within slot machine play compared with control group
– RGIC visitors were not more likely than control group visitors to start using RG strategies
The Osborne Group, 2007; Boutin et al., 2009
GameSense Evaluation History
2015
May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Apr.Mar.
Developed evaluation tools with MGC and MCCG; trained
GSAs to use tools
PPC opened; continued training and refining evaluation tools; used
preliminary results to improve protocol
Beginning of Wave 1
2016
2016
May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Apr.Mar.
Downloaded Wave 1 data
Delivered report to MGC
Beginning of Wave 2
2017
End of Wave 2
GameSense Evaluation History
Checklist• Purpose: formal, enduring record keeping system • Division responsible for secondary data analysis • Interaction Categories
Selected Findings: Checklist
• From December 1, 2015 until May 31, 2016…– GSAs completed 5,659 Checklists, which translates into
about 31 interactions each day.– GSAs interacted with at least 9,343 visitors, or about
52 visitors each day.• These are not necessarily unique visitors. If a Plainridge Park
patron had a conversation with a GSA in the morning, and again in the afternoon, she would be counted twice.
What Services do GSAs Provide?
What Services do GSAs Provide?
Simple71%
Instructive12%
Demonstration2%
Exchange15%
(n = 9,342 visitors)
Yes, it started as a Simple Inter-
action 79%
Yes, it started as an
Instructive Interaction 2%
Yes, it started as a Demonstration
Interaction 1%
No11%
Other/missing8%
Did This Exchange Interaction Begin as a Different Type?
Exchange Interactions (n = 908)
What Services do GSAs Provide?
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Proportion of all interactions (N = 5,659)Proportion of all non-Simple interactions (n = 1,713)
Major Categories of GSA Activities
Visitor Characteristics• GameSense Advisors perceived that…
• 41% of visitors in all 4 interaction types were “repeat customers”
• 7.5% of Exchange visitors were emotionally distressed and 0.5% of Exchange visitors were under the influence of drugs or alcohol
Selected Findings: Visitor Survey
Visitor Survey
85% response rate
• Reminder: Visitors in Exchange interactions represent 15% of all visitors.
Response Rate
My GameSense Advisor…
was caring
was helpful
was knowledeable
listened to me
0 10 20 30 40 50 60 70 80 90 100
Disagree/strongly disagree UncertainAgree/strongly agree
(n = 159)
Did you have any of these concerns when you began your conversation with the GameSense Advisor?
n %
I was curious about GameSense. 681 69.3I wanted to learn more about how gambling works. 383 39.0I wanted to learn more about strategies to keep gambling fun. 305 31.1I wanted to learn more about or enroll in the Play Management system. 40 4.1I wanted information about getting legal or financial help. 17 1.7I wanted to learn more about or enroll in the voluntary self exclusion. 21 2.1I wanted help for someone else. 18 1.8I wanted to get my credit suspended. 7 0.7I wanted the casino to suspend/reduce its marketing to me. 7 0.7I wanted help or information about problem gambling. 25 2.5I didn't have any of these concerns at the start of the conversation. 92 9.4
Visitors could select more than one response or no response. (n = 982)
To what extent was your primary question answered or your primary concern resolved?
(n = 982)
completely88%
somewhat4%
not at all1%
missing7%
Have you ever had any of these problems with your gambling?• Most visitors (83%) did not endorse any gambling-related problems
– 11% reported 1 problem; 5% two problems; and, 0.6% three problems
n %I had money problems because of my gambling. 12 7.0I had problems with friends or family members because of my gambling.
11 6.4
I had problems at work because of my gambling. 3 1.8I had legal problems because of my gambling. 4 2.3I had problems with my physical health because of my gambling. 3 1.8I had problems with my mental health because of my gambling. 1 0.6I was cheated while gambling. 3 1.8I had some other kind of problem because of my gambling. 4 2.3
Visitors could select more than one response or no response. (n = 171)
As a Result of your Conversation with a GameSense Advisor, will you…
Tell someone about the GameSense Info Center
Visit the GameSense website
Think about my own gambling
Think about someone else's gambling
Talk to someone I know you may have a gambling problem
Reduce my gambling behaviors
Increase my gambling behavior
0 10 20 30 40 50 60Percent endorsing
Visitors could select more than one response or no response. (n = 144)
Which Groups of People Might Benefit from Having a Conversation with a GameSense Advisor?
Anyone who gambles
People at risk for developing a gambling problem
People who have a gambling problem
0 10 20 30 40 50 60 70 80 90 100Percent endorsing
Visitors could select more than one response or no response (n = 171)
Visitor Survey Summary• Most visitors in Exchange interactions reported
that they…– liked their GSA – approached GSA out of curiosity rather than in need of
problem gambling help – felt that their concerns were completely resolved
Visitor Survey Summary, cont.• Most visitors in Exchange interactions reported that they…
– had not experienced problem gambling consequences– don’t plan to change their gambling behavior– don’t endorse GS to be beneficial for those who have a gambling
problem or are at-risk for a gambling problem• Comments were nearly all positive
Conclusions
Evaluation Loop Revisited
52 visitors per day = about 0.67% of daily PPC visitors
Effective in establishing rapport; will learn more from Wave 2
Appears safe for Exchange visitors (~15%)
Limitations• Representativeness of Visitor Survey findings
Limitations• Halo effect
– Visitors might have had generally positive feelings about the GSAs, which influenced their impressions of GSAs’ knowledge, helpfulness, etc.
• Some missing/incomplete data• These findings are only generalizable to the PPC
GameSense services
Future Work• What is the general perception of GameSense among all PPC
patrons? – SEIGMA patron intercept
• What do Plainridge Park employees think about GameSense? – Brief employee survey
• How does exposure to GameSense relate to responsible gambling knowledge and behavior?– Wave 2 data collection
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STOP THE PRESSES!• Wave 2 completed on February 8, 2017• Survey assess RG concepts and behaviors such as:
– Use of PlayMyWay, gambling myths, & gambling knowledge• Data included:
– 7878 checklists– 691 completed surveys
• 562 first time survey completers• 129 repeat survey completers
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RG Impact of GameSense (just a taste)• PlayMyWay use is related to GameSense use
– Those who reported more than one GSA interaction were more likely to enroll in PMW
• First time respondents who interacted with GSAs more were more likely to answers gambling-related questions accurately (e.g., A slot machine that has not paid out in a long time is “due” to pay out.)
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RG Impact of GameSense (second helping)• For the most part, GSA exposure was unrelated to RG
activity– PMW related to number of GSA interactions among first time
respondents; 8 other strategies were unrelated– Using win limits related to number of GSA interactions among
repeat respondents; financial loss and time limits were unrelated• GSA exposure was unrelated to knowledge of the most
likely outcome of any given slot machine play• More to come June 2017!
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Parting Thoughts on Responsible Gambling• Evaluation is a necessary component of Responsible
Gambling program development– Do no harm
• Few Responsible Gambling approaches have been evaluated, and potentially none are evaluated sufficiently
• Cooperation among key stakeholders is possible to advance evidence-based Responsible Gambling practice
Thank [email protected]
Main Websites:www.divisiononaddictions.orgwww.basisonline.orgwww.thetransparencyproject.org
Specialty Websites:Your First Step to Changehttp://www.basisonline.org/selfhelp_tools.htmlBrief Biosocial Gambling Screenhttp://divisiononaddictions.org/bbgs_new/
