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Cheryl Currie, PhD
Alberta Translational Health Chair & Assistant
Professor of Public Health, University of Lethbridge
What is done to resolve a
particular societal matter depends
on how it is framed
(Korn, 2002)


• All Canadian provinces provide funds to
promote responsible gambling

• But are we framing the matter in ways that
guide effective action?
What is Public Health?


 Science of prevention
 To fulfill society’s interest
in assuring conditions in
which people can be
healthy.
A Public Health Lens
Describe
gambling in
populations

Action

Determinants
of PG
Descriptive Epidemiology


Describe gambling
behaviour by:
Population-focused

Person
Time

Place
Population Health Focus
Individual Focus
 Chasing losses
 Cravings to gamble
 Health problems
 Financial problems

 Population Focus
 844,000 PGs in Canada
(2.4%)
 Higher in males
 Prevalence lowest in
Quebec, east coast
 Low treatment seeking
Determinants of PG


1. Biologic – Genetics, epigenetics
2. Environmental – Gambling environment
3. Individual – Choices, psychological mechanisms
4. Social – Poverty, unemployment,
discrimination, childhood trauma
Levels of Prevention


1. Primary Prevention – Prevent PG
2. Secondary Prevention – Catch
preclinical PG symptoms early
3. Tertiary Prevention – PG treatment
Levels of Prevention
Symptomatic
Clinical phase of
disease (PG)
Pre-Symptomatic
Early PG symptoms
The Problem with an
Educational Focus


Educational approaches to health
promotion have proved disappointingly
ineffective.
(Gilliam et al. 2012)
Example – Montana Meth Project


 45 000 TV ads, 35 000 radio ads, 10 000
print impressions, 1000 billboards
 Education campaign portrays the
consequences of meth use.

Findings – Anderson (2010)


 “...the effects on meth use are statistically
indistinguishable from zero.”
 Campaign did not contribute to a decrease in meth
use among youth.

 To better guide the allocation of resources this study
calls for a focus on the determinants of meth use.
What are the problems with
educating people?



1. Educating people on ‘how to behave better’
is often not that effective in eliciting
lasting behaviour change.
2. Some education-based behaviour change
theories are popular, but not necessarily
evidence-based.


Link to article
What are the problems with
educating people?



3. New people continue to enter the
population at an unaffected rate - who then
have to be
educated on “how
to behave better”
(Syme, 2008)
A shift in focus to reducing incidence not
prevalence
Link to
article
Wealth Distribution
Divide the 34 million people in Canada into 5 groups
each with 6.8 million people
 Wealthiest 20%
 Upper middle
 Middle
 Lower middle
 Bottom 20%

Question: What % of wealth is owned by each quintile?
Income Inequality & Mental Health


Big Picture Thinking


 Gambling redistributes $$ randomly among
participants.
 How could gambling revenues $$ be used to
redistribute wealth in society?
How can we structure the
gambling environment



To make individual’s
default decisions about
gambling responsible?
Link to
article
Finding the Right Balance


Gambling
Profits

Social
Responsibility
Rose - Preventative Medicine



 Personal lifestyle is socially conditioned.
 It makes little sense to expect individuals
to behave differently than their peers.
 It is more appropriate to seek a general
change in the circumstances which
facilitate behavioural adoption.
High-Risk Focus
Target:
High-risk gamblers
based on behaviour

Most
responsible

Average gambling
behaviour

Least
responsible
Where do the High-Risk come from?

Most
responsible

Average gambling
behaviour

Least
responsible
What Determines the Population Average?
The more
widespread a
cause, the less it
explains the
distribution of
cases.

Most
responsible

The hardest
causes to identify
are those
universally
present.

Average gambling
behaviour

Least
responsible
Comparing Populations
Average Blood Pressure

Link to full
reference
Comparing Populations


Causes of Cases
Similar in Alberta
& Quebec

8%

PG Prevalence

6%
4%

Causes of Incidence?

2%
0%
Alberta

Quebec
What is Our Question?
Why do some individuals have PG
Why do some populations have more PG?
Whole Population Target

Most
responsible

Average gambling
behaviour

Least
responsible

Edited from Frohlich and Potvin (2008)
The Problem!
In reality, this is what often happens

Frohlich and Potvin (2008): Link to article
The Problem
Increased PG Inequalities



 Those with higher SES derive more benefit
from whole population approaches
 Not addressed – underlying mechanisms in
society that lead to mental health inequalities
in various groups.

Determinants of PG



 Adverse Childhood Experiences
Link to
article
Framing Prevention Targets


1. High-risk population
2. Whole population
3. Vulnerable populations
Developing a Framework for
Responsible Gambling



1. Focus: Primary, secondary, tertiary prevention?

2. Strategies: Based on scientific theory & evidence?
3. Targets: Causes of cases or incidence?
Responsible Gambling
Where are We Now?



1. PG prevention programs not generally informed by
research evidence.

2. Most widely employed strategies are the least
effective (education, responsible gambling features,
self-exclusion)
3. No magic bullet strategy in PG literature.
Williams, Simpson & West (2012): Report Link
Finding the Right Balance


Gambling
Profits

Social
Responsibility
Refocusing Our Efforts to Promote
Responsible Gambling



Cheryl Currie, PhD
AIHS Translational Health Chair &
Assistant Professor of Public Health, University of
Lethbridge, cheryl.currie@uleth.ca

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Cheryl Currie: Refocusing our Efforts to Promote Responsible Gambling: The Importance of a Public Health Lens

  • 1. Cheryl Currie, PhD Alberta Translational Health Chair & Assistant Professor of Public Health, University of Lethbridge
  • 2. What is done to resolve a particular societal matter depends on how it is framed (Korn, 2002)  • All Canadian provinces provide funds to promote responsible gambling • But are we framing the matter in ways that guide effective action?
  • 3. What is Public Health?   Science of prevention  To fulfill society’s interest in assuring conditions in which people can be healthy.
  • 4. A Public Health Lens Describe gambling in populations Action Determinants of PG
  • 5. Descriptive Epidemiology  Describe gambling behaviour by: Population-focused Person Time Place
  • 6. Population Health Focus Individual Focus  Chasing losses  Cravings to gamble  Health problems  Financial problems  Population Focus  844,000 PGs in Canada (2.4%)  Higher in males  Prevalence lowest in Quebec, east coast  Low treatment seeking
  • 7. Determinants of PG  1. Biologic – Genetics, epigenetics 2. Environmental – Gambling environment 3. Individual – Choices, psychological mechanisms 4. Social – Poverty, unemployment, discrimination, childhood trauma
  • 8.
  • 9. Levels of Prevention  1. Primary Prevention – Prevent PG 2. Secondary Prevention – Catch preclinical PG symptoms early 3. Tertiary Prevention – PG treatment
  • 10. Levels of Prevention Symptomatic Clinical phase of disease (PG) Pre-Symptomatic Early PG symptoms
  • 11.
  • 12. The Problem with an Educational Focus  Educational approaches to health promotion have proved disappointingly ineffective. (Gilliam et al. 2012)
  • 13. Example – Montana Meth Project   45 000 TV ads, 35 000 radio ads, 10 000 print impressions, 1000 billboards  Education campaign portrays the consequences of meth use.
  • 14.
  • 15. Findings – Anderson (2010)   “...the effects on meth use are statistically indistinguishable from zero.”  Campaign did not contribute to a decrease in meth use among youth.  To better guide the allocation of resources this study calls for a focus on the determinants of meth use.
  • 16. What are the problems with educating people?  1. Educating people on ‘how to behave better’ is often not that effective in eliciting lasting behaviour change. 2. Some education-based behaviour change theories are popular, but not necessarily evidence-based.
  • 18. What are the problems with educating people?  3. New people continue to enter the population at an unaffected rate - who then have to be educated on “how to behave better” (Syme, 2008)
  • 19. A shift in focus to reducing incidence not prevalence
  • 21. Wealth Distribution Divide the 34 million people in Canada into 5 groups each with 6.8 million people  Wealthiest 20%  Upper middle  Middle  Lower middle  Bottom 20% Question: What % of wealth is owned by each quintile?
  • 22. Income Inequality & Mental Health 
  • 23. Big Picture Thinking   Gambling redistributes $$ randomly among participants.  How could gambling revenues $$ be used to redistribute wealth in society?
  • 24. How can we structure the gambling environment  To make individual’s default decisions about gambling responsible?
  • 26. Finding the Right Balance  Gambling Profits Social Responsibility
  • 27. Rose - Preventative Medicine   Personal lifestyle is socially conditioned.  It makes little sense to expect individuals to behave differently than their peers.  It is more appropriate to seek a general change in the circumstances which facilitate behavioural adoption.
  • 28.
  • 29. High-Risk Focus Target: High-risk gamblers based on behaviour Most responsible Average gambling behaviour Least responsible
  • 30. Where do the High-Risk come from? Most responsible Average gambling behaviour Least responsible
  • 31. What Determines the Population Average? The more widespread a cause, the less it explains the distribution of cases. Most responsible The hardest causes to identify are those universally present. Average gambling behaviour Least responsible
  • 32. Comparing Populations Average Blood Pressure Link to full reference
  • 33. Comparing Populations  Causes of Cases Similar in Alberta & Quebec 8% PG Prevalence 6% 4% Causes of Incidence? 2% 0% Alberta Quebec
  • 34.
  • 35. What is Our Question? Why do some individuals have PG Why do some populations have more PG?
  • 36. Whole Population Target Most responsible Average gambling behaviour Least responsible Edited from Frohlich and Potvin (2008)
  • 37. The Problem! In reality, this is what often happens Frohlich and Potvin (2008): Link to article
  • 38. The Problem Increased PG Inequalities   Those with higher SES derive more benefit from whole population approaches  Not addressed – underlying mechanisms in society that lead to mental health inequalities in various groups.
  • 39.
  • 40.
  • 41. Determinants of PG   Adverse Childhood Experiences
  • 43. Framing Prevention Targets  1. High-risk population 2. Whole population 3. Vulnerable populations
  • 44. Developing a Framework for Responsible Gambling  1. Focus: Primary, secondary, tertiary prevention? 2. Strategies: Based on scientific theory & evidence? 3. Targets: Causes of cases or incidence?
  • 45. Responsible Gambling Where are We Now?  1. PG prevention programs not generally informed by research evidence. 2. Most widely employed strategies are the least effective (education, responsible gambling features, self-exclusion) 3. No magic bullet strategy in PG literature. Williams, Simpson & West (2012): Report Link
  • 46. Finding the Right Balance  Gambling Profits Social Responsibility
  • 47. Refocusing Our Efforts to Promote Responsible Gambling  Cheryl Currie, PhD AIHS Translational Health Chair & Assistant Professor of Public Health, University of Lethbridge, cheryl.currie@uleth.ca